10 Dec 2020 Edward Mallaby · Prevention of Future Deaths report Sunderland
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Concerns raised 1
Lack of clarity about required observation frequency for residents at risk of falls View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
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Each statement is shown once, even when linked to more than one concern.
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Edward Mallaby · 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
Edward Mallaby died after a boxed television fell onto him in his room at Alexandra View Care Home, causing injuries, bedbound status and pneumonia. Concerns included the handling and secure storage of potentially hazardous personal property, failure or absence of alerts when he was out of bed, unclear observation arrangements, and the lack of a rapid learning exercise or deadline for policy and training review.
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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 clarity about required observation frequency for residents at risk of falls
Wider context from the report “4. Although the deceased had a falls risk assessment, it was not clear whether he was subject to hourly or half hourly observations , or whether the door to his room was to be open or not.
” Source location Edward Mallaby · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issue updated resident belongings, resident admission, and falls management policies across the Group, with staff read-and-sign confirmation and Alexandra View supervision sessions.
Verbatim wording from the response “Please find enclosed updated policies in respect of:” Source location 2020-0277-Response-from-Roseberry-Care-Centres-Redacted
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How this respondent action was interpreted
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PFD Monitor interpretation Introduce an Observation and Monitoring form, update the Falls Risk Assessment, and require at least hourly sensor-mat checks throughout each shift with daily senior-management monitoring at Alexandra View.
Verbatim wording from the response “In addition, I have introduced an Observation and Monitoring form (also enclosed) to be used in accordance with the updated Management and Prevention of Falls policy and updated the Falls Risk Assessment to reference this new record (attached). At the time of Mr Mallaby’s accident, sensor mats were checked at each shift changeover and recorded on the handover by the person in charge. The introduction of this form will ensure sensor equipment is checked for its position and that it is in working order throughout the shift and a minimum of hourly. This amendment to policy and additional checking is being monitored daily at Alexandra View by on site senior management.” Source location 2020-0277-Response-from-Roseberry-Care-Centres-Redacted
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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 Repeat Prevention and Management of Falls training for Alexandra View staff.
Verbatim wording from the response “The staff at Alexandra View have also repeated their Prevention and Management of Falls training to refresh their knowledge; all staff successfully completed this by 7th January 2021.” Source location 2020-0277-Response-from-Roseberry-Care-Centres-Redacted
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8 Dec 2020 Ann Doris Stillwell · Prevention of Future Deaths report East London
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Concerns raised 1
Failure to authorise 1:1 care for a person at high risk of falls View source
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Each statement is shown once, even when linked to more than one concern.
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Ann Doris Stillwell · 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
Ann Doris Stillwell, who was at high risk of falls, sustained a left-sided neck of femur fracture after a fall in her care home on 3 July 2020 and died from complications of her injuries on 5 July 2020. The principal concern was that 1:1 care was not authorised despite the identified risk, and the report states that this would have been the only way to mitigate the particular risk she presented to herself.
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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 authorise 1:1 care for a person at high risk of falls
Wider context from the report “1. Mrs Stillwell was at high risk of falls during the entirety of the period of 25th May 2020 until the 3rd July 2020. During that period the Commissioner for her care did not authorise 1:1 care. 1:1 care would have been the only way in which the particular risk presented by Mrs Stillwell to herself could have been mitigated.
” Source location Ann Doris Stillwell · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Route all one-to-one care requests to the Head of Service and senior nurse assessor for a response within two hours.
Verbatim wording from the response “4. We have identified that requests for 1 to 1s come through to different people in the CHC Team and the level of information given is sometimes variable. We have now introduced a requirement for requests for 1 to 1s to be sent to the Head of Service and a senior nurse assessor who will provide a response to the request within 2 hours.” Source location 2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
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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 Require supporting risk and care evidence, with reassessment before extending one-to-one care beyond the usual 14-day authorisation.
Verbatim wording from the response “5. If the information is not complete, then the hospital discharge team is asked to forward all falls risk assessments, care diaries and behaviour charts as appropriate to the Head of Service or senior nurse assessor so that they can confirm a decision. Evidence is needed as to whether this level of support is required during the daytime only or the full 24 hours. Many people are nursed on enhanced observations or in a cohort /bay in hospital do not go on to require this level of support in the care home.” Source location 2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
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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 Escalate care-home one-to-one requests made directly to brokerage staff to a senior clinician and embed this escalation in CHC electronic processes.
Verbatim wording from the response “7. We are introducing an additional safeguard to ensure that any requests for 1 to 1s submitted to the brokerage team directly by a care home are brought to the attention of a senior clinician. The following actions have been agreed:” Source location 2021-0091-Response-from-Clinical-Commissioning-Group-Redacted
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How this respondent position was interpreted
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PFD Monitor interpretation No change to national continuing healthcare policy is considered necessary in response to the concerns.
Verbatim wording from the response “The Department has considered the concerns raised in your report and in this instance, we do not consider that a change in national policy is required. However, Departmental officials will work with NHS England, which is responsible for providing assurance on the actions of CCGs, to consider the specific circumstances of this case and whether further regional monitoring may be required.” Source location 2021-0091-Response-from-Dept-of-Health-and-Social-Care-Redacted
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How this respondent position was interpreted
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PFD Monitor interpretation Clinical commissioning groups are responsible for commissioning one-to-one care within their local areas.
Verbatim wording from the response “CCGs are responsible for the commissioning of 1:1 care within their local areas. I understand that Barking and Dagenham Havering, and Redbridge CCGs, have provided a joint response which sets out the actions taken to learn from the findings presented, following Mrs Stillwell’s death.” Source location 2021-0091-Response-from-Dept-of-Health-and-Social-Care-Redacted
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9 Aug 2020 Peter William Howarth · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Lack of investigations into falls in care and nursing homes View source
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Each statement is shown once, even when linked to more than one concern.
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Peter William Howarth · 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
Peter William Howarth, who had complex underlying health problems, died in hospital after sustaining injuries in a number of falls, including a fractured neck of femur requiring surgery. The report raised concern that Borough Care had not investigated the fall at the care home that led to his final hospital admission.
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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 investigations into falls in care and nursing homes
Wider context from the report “1. The court heard evidence that, despite the fact Mr Howarth was injured in a fall at his care home which led to his final admission to hospital, Borough Care has not undertaken any investigation into the circumstances of that fall . Robust investigations into falls in care and nursing homes are essential with a view to considering whether or not there is any learning to be derived from the incident for the benefit of other residents with a view to reducing the risk of death arising from falls in similar circumstances.
” Source location Peter William Howarth · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete weekly falls analyses and record actions taken.
Verbatim wording from the response “Managers must now complete a weekly falls analysis and detail all actions taken. If a resident has more than 2 falls in any period of 2 weeks a referral must be made to their GP or to the falls clinic.” Source location 2020-0171-Response-from-Borough-Care_Redacted.pdf
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13 Jul 2020 John Cheetham · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to prioritise timely risk assessments for elderly patients at risk of falls 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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Each statement is shown once, even when linked to more than one concern.
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John Cheetham · 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 Cheetham died at Stepping Hill Hospital on 19 January 2020 after an unwitnessed fall while awaiting a hospital bed in the Emergency Department, sustaining a subarachnoid haemorrhage and subsequently developing cerebral oedema and Clostridium difficile infection. The concerns included prolonged Emergency Department waits caused by bed-capacity pressures, shortages of appropriately trained nurses, and failure to complete a falls-risk assessment at the earliest opportunity, increasing risks for elderly patients vulnerable to falls.
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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 prioritise timely risk assessments for elderly patients at risk of falls
Wider context from the report “5. In his case a risk assessment was not carried out at the earliest opportunity . The inquest heard that when an ED is facing the demands caused by capacity issues risk assessments are not always prioritised increasing the risks faced by elderly patients at risk of falls .
” Source location John Cheetham · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use patient safety checklists in all Greater Manchester Emergency Departments and monitor their use through regular clinical-lead walkrounds.
Verbatim wording from the response “Ensuring patient safety and quality of care in Emergency Departments, particularly in times of increased pressure, is highly important in Greater Manchester. All of the acute trusts in Greater Manchester now utilise a patient safety checklist in their Emergency Departments. These checklists are time-based frameworks that outline clinical tasks that need completing for each patient in the first hours of their admittance to an ED. It ensures that assessments and tests happen in a timely way in order to improve patient satisfaction and reduce risks. These have been adopted from the national checklist template which was published in 2017 and which has been proven to improve clinical processes and reduce harm and serious incidents from unrecognised patient deterioration. In addition to this, clinical leads from Clinical Commissioning Groups” Source location 2020-0140-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership_Redcated.pdf
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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 Stockport health system partners are responsible for implementing improvements addressing urgent and emergency care safety concerns.
Verbatim wording from the response “It is essential that health system partners in Stockport take the necessary action, quickly, to respond to these findings and improve the safety and quality of urgent and emergency services in Stockport.” Source location 2020-0140-Response-from-the-Department-of-Health-and-Social-Care.pdf
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8 Jun 2020 Mildred Horrex · Prevention of Future Deaths report West Sussex
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Concerns raised 1
Inadequate fall 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.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Mildred Horrex · 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
Mildred Horrex suffered an unwitnessed fall while sleeping in a chair at Pelham House on 30 December 2017, sustaining fractures to her C1 and C2 vertebrae, and died in hospital on 18 January 2018. The concerns identified were poor and sometimes inaccurate record keeping, insufficient information for an adequate fall-risk assessment, and discrepancies between medication records and the amount of medication held that were not detected by audits.
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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 fall risk assessments
Wider context from the report “1. During the course of the Inquest it was clear that overall the record keeping in respect of Mildred was poor. There was insufficient information taken about Mildred by the home before her admission to Pelham House, the information that was taken was at times inaccurate and this lead to an inadequate fall risk assessment being insufficient .
” Source location Mildred Horrex · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a care-plan system containing risk assessments, audit trails, and resident-relative access to current care information.
Verbatim wording from the response “to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of the MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives wish to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed” Source location 2020-0126-Response-from-Pelham-House.pdf
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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 Employ an external auditor to conduct monthly care-plan and medication audits and provide additional advice when needed.
Verbatim wording from the response “to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of the MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives wish to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed” Source location 2020-0126-Response-from-Pelham-House.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review care plans and risk assessments monthly and after significant changes, with relatives signing care-plan reviews.
Verbatim wording from the response “to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of the MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives wish to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed” Source location 2020-0126-Response-from-Pelham-House.pdf
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The available admission information supported a sufficient falls risk assessment, disputing that inadequate information caused an insufficient assessment.
Verbatim wording from the response “Response
Prior to admission the family had a meeting with the manager of the home and the deputy manager, they themselves provided all the information to us everything they believed relevant, my deputy questioned them about falls history and they said mum is NOT a high risk of falling having only one fall whilst in her own home, all information was provided by themselves, the risk assessment was sufficient at the time it was extremely difficult to explain the workings of the system in a court room with individuals that have never used a care plan system before I believe this is why the coroner made the comment about record keeping, ( the paramedic in the court room understood perfectly well as he was familiar with the system) the system we used took the information provided by the family and generated a falls score, MH had not fallen in Pelham prior to her death and this meant that a” Source location 2020-0126-Response-from-Pelham-House.pdf
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27 Apr 2020 Evelyn Ross · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Failure to follow falls risk policy View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Action
Amend the falls policy to require documented 24-hour review of individualised additional interventions, obtain ratification, and disseminate the update across the Trust.
Stated by Manchester University NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 5 June 2020. View source
Action
Deliver falls-risk training and support, including Hot Topic sessions, face-to-face education, and mandatory interactive e-learning for clinical staff.
Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source
Action
Audit falls-risk assessments and policy compliance through ward, hot-spot, Matron, Trust-wide, and annual accreditation reviews.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Use the updated falls policy, electronic risk-assessment records, Ward 6 and hospital falls action plans, and multidisciplinary task groups to coordinate falls prevention.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Provide Ward Managers with falls-risk-reduction checklists and prompts to support consistent assessment, care planning, and management.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Operate falls harm-review and Harm-Free Care meetings to investigate falls, identify learning, implement preventative measures, and monitor compliance.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Maintain enhanced falls oversight through care reviews, live documentation audits, bay tagging, senior nursing checks, intentional-rounding projects, and falls-equipment compliance monitoring.
Stated by Manchester University NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 5 June 2020. View source
Action
Relaunch staff competency checklists and falls-management prompts across WTWA to identify training needs and support guided reflection.
Stated by Manchester University NHS Foundation TrustStated in progressThe respondent said that this action was in progress when they made their response on 5 June 2020. View source See 5 more actions
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Evelyn Ross · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Evelyn Ross fractured her hip, underwent surgery, and was transferred for rehabilitation. After a fall, delayed CT scanning identified an acute on chronic subdural haematoma, followed by surgery, deterioration with hospital-acquired pneumonia, and her death on 23 September 2019. Concerns included staffing shortages, delays arranging discharge care, inadequate documentation, failure to follow the falls risk policy, and a lack of clear regular orthogeriatric consultant reviews and escalation when her condition deteriorated.
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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 follow falls risk policy
Wider context from the report “4. The inquest heard that the Trust had not followed their own falls risk policy in relation to Mrs Ross.
” Source location Evelyn Ross · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Amend the falls policy to require documented 24-hour review of individualised additional interventions, obtain ratification, and disseminate the update across the Trust.
Verbatim wording from the response “When a nursing review of Mrs Ross’ care was undertaken prior to the Inquest, it was identified that the individualised additional intervention section of the falls care plan were not reviewed every 24 hours. It was noted however that at the time there was a discrepancy in the Trust falls policy which did not specifically refer to a requirement to undertake this, and document this review every 24 hours. Subsequently, the Falls Specialist Nurse was made aware of the discrepancy in the falls policy. This amendment to the policy has been incorporated with further updates to the policy (to reduce the need for multiple policy revisions being shared with staff intermittently, and to provide one comprehensive update).” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver falls-risk training and support, including Hot Topic sessions, face-to-face education, and mandatory interactive e-learning for clinical staff.
Verbatim wording from the response “As of April 2020, the Matron for Quality Improvement and Patient Experience’s compliance audit for falls risk assessment completion and falls care plan implementation was 90%. Hot Topic Sessions covering falls risk reduction and management have been launched in June 2020. So far this month across Trafford General Hospital 30 members of staff, including six members of staff from Ward 6, have attended the training, with several further sessions to take place this month to capture further staff.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Audit falls-risk assessments and policy compliance through ward, hot-spot, Matron, Trust-wide, and annual accreditation reviews.
Verbatim wording from the response “As part of the Monthly Matron Review proforma, a sample of patient assessments are audited to monitor the ongoing completion of Falls Risk Assessments. Results of these audits are highlighted at the Monthly Matron Confirm and Challenge meetings with Ward Managers.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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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 Use the updated falls policy, electronic risk-assessment records, Ward 6 and hospital falls action plans, and multidisciplinary task groups to coordinate falls prevention.
Verbatim wording from the response “Prior to Mrs Ross’ admission, the Trust had recently, in April 2019, implemented a new Trust-wide updated Falls Management Policy and I enclose a copy of this for your information (Appendix 2). I am very sorry to hear that there was evidence that aspects of the falls policy were not adhered to in Mrs Ross’ case.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide Ward Managers with falls-risk-reduction checklists and prompts to support consistent assessment, care planning, and management.
Verbatim wording from the response “Each individual Ward Manager has been provided with a checklist to support falls risk reduction, as well as falls reduction and management prompts.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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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 Operate falls harm-review and Harm-Free Care meetings to investigate falls, identify learning, implement preventative measures, and monitor compliance.
Verbatim wording from the response “Falls resulting in patient harm are presented to the monthly Falls Accountability meeting. Thematic analysis is considered in order to establish learning arising out of patient incidents in respect of falls and to implement preventative measures to improve patient safety.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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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 Maintain enhanced falls oversight through care reviews, live documentation audits, bay tagging, senior nursing checks, intentional-rounding projects, and falls-equipment compliance monitoring.
Verbatim wording from the response “A number of initiatives are already in place at Trafford General Hospital to ensure oversight of falls across the hospital including Matrons/Lead Nurse completing their enhanced care reviews three times per week as per policy, live documentation audits, relaunching the Bay Tagging initiative on hot spot areas and firmly challenging staff who do not adhere to policy, quality improvement projects in relation to intentional rounding and increased daily senior nursing on clinical areas to ensure correct adherence to Enhanced Observations of Care Policy and proper use of falls sensor equipment.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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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 Relaunch staff competency checklists and falls-management prompts across WTWA to identify training needs and support guided reflection.
Verbatim wording from the response “In addition to these assurance processes, senior nursing teams across WTWA are being asked to relaunch both the Staff Competency Checklist for the Risk Reduction and Management of Inpatient Falls, and the Falls Risk Reduction and Management Prompts, to ensure staff feels comfortable and confident in falls risk assessment and care planning; and that additional training needs are highlighted appropriately. This process also allows for staff managing individuals involved in falls incidents to consider their competency level and ensure guided reflection is appropriately provided.” Source location 2020-0106-Response-from-Manchester-University-NHS-Foundation-Trust_Redacted-1.pdf
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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 NICE falls guidance provides the relevant framework for identifying and addressing inpatient environmental and individual fall risks.
Verbatim wording from the response “Finally, with regard to falls prevention, the National Institute for Health and Care Excellence (NICE) has published a clinical guideline on Falls in older people: assessing risk and prevention (CG161³) that includes guidance on preventing falls in older people during a hospital stay. The guideline says:” Source location 2020-0106-Response-from-Department-of-Health-and-Social-Care.pdf
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17 Dec 2019 Barry Jack Gordon Liffen · Prevention of Future Deaths report Inner West London
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Concerns raised 1
Failure to seek clinical assessment for frail residents following falls View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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Barry Jack Gordon Liffen · 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
Barry Jack Gordon Liffen, who had dementia and other chronic illnesses and was taking anticoagulants, fell at his sheltered accommodation on 10 March 2019 and sustained a head injury causing subdural bleeding. His condition later deteriorated, and he died in hospital on 11 May 2019 after developing recurrent pneumonia. The concerns identified were the need for clinical assessment after falls and when staff observe deterioration in frail residents at Glebelands.
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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 seek clinical assessment for frail residents following falls
Wider context from the report “1. That clinical assessment be sought for frail persons resident at Glebelands following falls .
” Source location Barry Jack Gordon Liffen · Prevention of Future Deaths report
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27 Nov 2019 Andrew Richard Hogg · Prevention of Future Deaths report Manchester South
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Concerns raised 5
Failure to review and reassess falls risk after sequential falls View source Lack of an escalation pathway following sequential falls View source Lack of an adequate falls assessment policy View source
Failure to complete and update falls-related records View source Failure to proactively implement measures to reduce escalating falls risk View source See 2 more concerns
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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Andrew Richard Hogg · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Andrew Richard Hogg, who had Parkinson’s disease and possible dementia, died on 6 May 2019 after a fall at Meadway Court Care Home caused a head injury and subdural haematoma. The principal concerns were the absence of adequate falls assessment, escalation, investigation and proactive measures to reduce the risk after his repeated falls.
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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 review and reassess falls risk after sequential falls
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019 . There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” Source location Andrew Richard Hogg · Prevention of Future Deaths report
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 an escalation pathway following sequential falls
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” Source location Andrew Richard Hogg · Prevention of Future Deaths report
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 an adequate falls assessment policy
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” Source location Andrew Richard Hogg · Prevention of Future Deaths report
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 complete and update falls-related records
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record .
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” Source location Andrew Richard Hogg · Prevention of Future Deaths report
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 proactively implement measures to reduce escalating falls risk
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk .
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision .
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” Source location Andrew Richard Hogg · Prevention of Future Deaths report
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 Review falls weekly in the PCS system, document actions, and update affected residents’ support plans.
Verbatim wording from the response “However, to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. Managers will print the falls log for the week and add notes as to what actions have been taken. These notes will also be added to the support plans of those residents involved. Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
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 Arrange a GP or CPN review for any resident experiencing more than two falls within two weeks.
Verbatim wording from the response “However, to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. Managers will print the falls log for the week and add notes as to what actions have been taken. These notes will also be added to the support plans of those residents involved. Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
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 Audit the falls-review process monthly through Area Managers’ audits.
Verbatim wording from the response “This process will be reviewed by our Area Managers as part of their monthly audit.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Each individual fall was dealt with appropriately, although the overall number and timing of falls were not reviewed at that time.
Verbatim wording from the response “I have investigated your concerns and I agree that each fall had been dealt with appropriately, but a review into the number of falls and the timescale in which the falls occurred did not appear to happen at that time.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
Open published response
30 Sep 2019 Mary Jones · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Delays in completing falls risk assessments View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Mary 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
Mary Jones had an accidental unwitnessed fall, was treated surgically and transferred for rehabilitation, and died on 3 March 2019 after developing acute pneumonia alongside congestive heart failure and acute kidney injury. Concerns included an out-of-hours transfer and admission, delayed falls-risk assessment, poor fluid-chart documentation, loss of records during an IT merger, absent or untraceable nutrition-related referrals, and no clear clinical review of fluid-chart outcomes.
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 Delays in completing falls risk assessments
Wider context from the report “2. The falls risk assessment was completed outside the Trust target time primarily as a result of the late arrival;
” Source location Mary Jones · Prevention of Future Deaths report
Open source report
Concerns raised 3
Failure to categorise residents with repeated falls as high risk View source Failure to reassess residents' falls risk following further falls View source Incomplete staff training in falls-risk management View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Edna Drury Evans · 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
Edna Drury Evans became a resident at Emral House Nursing Home after a number of falls and experienced further incidents while resident. Her final unwitnessed fall on 27 April 2019 caused a significant head injury, and she died from a subdural haematoma on 2 May 2019. Concerns included incomplete falls-risk training, her categorisation as medium rather than high risk despite repeated falls, and the absence of evidence of reassessment after further falls or of a policy requiring it.
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 categorise residents with repeated falls as high risk
Wider context from the report “The evidence provided at the inquest indicated that staff at the home were currently undergoing training in relation to the risk of falls but that this had not yet been fully completed.
Furthermore, although the manager indicated in her evidence that a resident who had sustained a number of falls would be expected to be categorised as “high risk” , she stated that Mrs Evans was only a “medium risk” despite the fact that she had falls prior to admission and continued to have a number of falls whilst a resident .
Although there was an assessment of Mrs Evans on the 11th of January (ie shortly after she became a resident) there is no evidence to suggest that there was any reassessment following further falls nor any apparent policy or protocol requiring this.
” Source location Edna Drury Evans · 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 reassess residents' falls risk following further falls
Wider context from the report “The evidence provided at the inquest indicated that staff at the home were currently undergoing training in relation to the risk of falls but that this had not yet been fully completed.
Furthermore, although the manager indicated in her evidence that a resident who had sustained a number of falls would be expected to be categorised as “high risk”, she stated that Mrs Evans was only a “medium risk” despite the fact that she had falls prior to admission and continued to have a number of falls whilst a resident.
Although there was an assessment of Mrs Evans on the 11th of January (ie shortly after she became a resident) there is no evidence to suggest that there was any reassessment following further falls nor any apparent policy or protocol requiring this .
” Source location Edna Drury Evans · 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 Incomplete staff training in falls-risk management
Wider context from the report “The evidence provided at the inquest indicated that staff at the home were currently undergoing training in relation to the risk of falls but that this had not yet been fully completed .
Furthermore, although the manager indicated in her evidence that a resident who had sustained a number of falls would be expected to be categorised as “high risk”, she stated that Mrs Evans was only a “medium risk” despite the fact that she had falls prior to admission and continued to have a number of falls whilst a resident.
Although there was an assessment of Mrs Evans on the 11th of January (ie shortly after she became a resident) there is no evidence to suggest that there was any reassessment following further falls nor any apparent policy or protocol requiring this.
” Source location Edna Drury Evans · Prevention of Future Deaths report
Open source report
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Includes assessment, care planning, equipment, supervision, handover, referral, reporting, post-fall response and assurance explicitly dedicated to falls risk.
