Concerns raised 1
Lack of risk assessment for falls and pressure sore risk View source
This report raised 1 other concern. 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
Lambton House
Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.
View source
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AI-generated summary
Name not published · 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
The deceased, who had a history of falls and was assessed as being at risk of falling, was found on the floor after an unwitnessed night and sustained injuries that subsequently led to her death. Concerns included the absence of adequate risk assessments for falls and pressure sores, and the failure to identify that a new mattress was unsuitable for her.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of risk assessment for falls and pressure sore risk
Wider context from the report “(1) It became apparent that a risk assessment was not completed in relation to the deceased's falls and the pressure sore risk . The deceased was found on the floor after an unwitnessed night by a carer at approximately 4.00 hours. She sustained injuries which subsequently led to her death.
” Source location Name not published · 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 Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.
Verbatim wording from the response “Steps are being taken to further minimise the risk that resident's face in situations such as this. Lambton House is currently in the process of phasing in through “Home Loans” the provision of air flow mattresses, where there has been an assessed need to aid pressure relief care. All new air flow mattresses are compatible with bed based pressure sensors. The aim is to eliminate the need for floor based pressure sensors, which in themselves can also create a risk of falls/trips.” Source location 2016-0423-Response-by-Lambton-House-Care-Home
Open published response
24 Nov 2016 Mrs Beryl Farmer · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2
Lack of completed falls risk assessments View source Failure to justify moving patients at risk of falls from monitored to unmonitored bays View source
This report raised 2 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
Mrs Beryl Farmer · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mrs Farmer was admitted to hospital with severe hypocalcaemia and postural hypotension, fell from her bed and sustained facial and head injuries, and was discharged without a documented falls risk assessment. She was readmitted after developing headaches, was diagnosed with a subdural haemorrhage, later developed seizures, and died; concerns included inadequate falls-risk assessment, moving her to an unmonitored bay, limited neurological observations, and no CT head scan after the fall.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of completed falls risk assessments
Wider context from the report “1. Evidence emerged during the inquest that Mrs Farmer had a risk of a falling (moderate to high risk). There was no evidence that a falls risk assessment had been completed.
” Source location Mrs Beryl Farmer · 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 justify moving patients at risk of falls from monitored to unmonitored bays
Wider context from the report “2. Given the risks of falls, there was no clear justification for moving her from a monitored bay to an unmonitored bay .
” Source location Mrs Beryl Farmer · Prevention of Future Deaths report
Open source report
7 Nov 2016 Maurice ISAACS · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 1
Failure to provide indicated continuous 1:1 supervision for a high falls-risk patient View source
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Cardiff & Vale 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. 5
Cardiff & Vale University LHB
Commence and regularly review falls care plans for all patients identified as at risk.
View source
Cardiff & Vale University LHB
Discuss falls risk assessment outcomes and 1:1 specialling requirements with families and carers, incorporating their views.
View source
Cardiff & Vale University LHB
Restrict staff assigned to specialling to duties that do not take them away from providing specialling.
View source
Cardiff & Vale University LHB
Benchmark enhanced observational care against other organisations across Wales and England.
View source
Cardiff & Vale University LHB
Carry out the Specialling of Patients project in Medicine Clinical Board wards.
View source See 2 more actions
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AI-generated summary
Maurice ISAACS · 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
Maurice ISAACS, who had dementia and other chronic health conditions, was admitted to hospital after deteriorating and suffered multiple falls. He fell from his bed on 12 June 2016, sustained a head injury and died two days later. Concerns included shortcomings in falls-risk assessment, care planning and supervision, as well as failures in carrying out and overseeing neurological observations after the final fall.
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 indicated continuous 1:1 supervision for a high falls-risk patient
Wider context from the report “(1) The investigation into his death revealed shortcomings in the way in which his risk of falls were assessed and recorded. For example, no clear care plan was introduced until after the fourth fall. Although there were some occasions when he was given 1:1 care that was not consistent and despite the increasing number of falls, he was never given true 1:1 supervision / observation . Despite the medical notes showing that this should have been in place at the time of his final fall, the reality on the ward was that he was being observed by a nurse on a 1:4 basis . Despite the ward being staffed to "agreed staffing levels" the evidence showed that on the ground, on occasions, this was simply not enough staff to manage the demands of the ward.
His condition was so variable and unpredictable, and against a background of so many falls, 1:1 care was indicated . The evidence showed that whilst there was a review of his situation after each fall, a more 'holistic' approach, recognising the dangers posed by his unpredictable behaviour, and the causes of that, might have prevented so many falls.
” Source location Maurice ISAACS · 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 Commence and regularly review falls care plans for all patients identified as at risk.
Verbatim wording from the response “The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Discuss falls risk assessment outcomes and 1:1 specialling requirements with families and carers, incorporating their views.
Verbatim wording from the response “The Medicine Clinical Board, in conjunction with all Directorates, have put in place the following key changes to identify how risk is assessed and the level of specialling that a patient requires to support a more holistic approach. When completing the falls risk assessment, all patients identified as at risk have a falls care plan commenced. This care plan is reviewed weekly, or more frequently as the patient’s health and requirements change. Since the tragic incident involving Mr I, the Clinical Board recognises the need for more robust discussion of the risk assessment outcome and the need for 1:1 specialling with families/carers. Families and carers are now actively encouraged to share their opinions if they feel 1:1 specialling is not appropriate for their relative or if they may respond poorly to this type of enhanced monitoring.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Restrict staff assigned to specialling to duties that do not take them away from providing specialling.
Verbatim wording from the response “Nursing staff that have been identified to provide specialling have been informed that they are not to participate in care that would take them away from their role of providing specialling. The Clinical Board are currently undertaking benchmarking of enhanced observational care within other organisations across Wales and England.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Benchmark enhanced observational care against other organisations across Wales and England.
Verbatim wording from the response “Nursing staff that have been identified to provide specialling have been informed that they are not to participate in care that would take them away from their role of providing specialling. The Clinical Board are currently undertaking benchmarking of enhanced observational care within other organisations across Wales and England.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
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 Carry out the Specialling of Patients project in Medicine Clinical Board wards.
Verbatim wording from the response “The UHB is currently carrying out a project on the ‘Specialling of patients’ which we hope to have in place in the Medicine Clinical Board ward areas in February 2017.” Source location 2016-0411-Response-by-Uiniversity-Hospital-of-Wales
Open published response
26 Aug 2016 Maureen Patricia FLYNN · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1
Failure to complete required falls risk assessments View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Maureen Patricia FLYNN · 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
Maureen Patricia FLYNN was admitted to hospital with a urinary tract infection and later suffered a fall from her bedside chair, fracturing her left hip. She underwent surgery, subsequently developed a chest infection that did not respond to antibiotics, and died on 7 May 2016. Concerns included the incomplete falls risk assessment, staff not being alerted to this, and the Patient Safety Investigation not identifying the omission.
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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 complete required falls risk assessments
Wider context from the report “The evidence at the Inquest suggested that if, from the falls risk assessment, there were concerns as to Mrs Flynn’s mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover. However, as the assessment had not been completed out no-one knew, least of all the HCA.
It is of concern to me that those caring for a patient were ignorant of the fact that Mrs Flynn’s falls risk assessment had not been completed . It is clear that the HCA was unaware. It is reasonable for staff, in my view, to assume that all assessments have been appropriately carried out and completed. Why would the HCA have thought otherwise given the high falls risk sign above Mrs Flynn’s bed?
It would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed. My concern extends to any other assessment required for a patient’s safety and well-being.
I am further concerned that the Patient Safety Investigation did not identify the fact that the falls risk assessment had not been completed.
” Source location Maureen Patricia FLYNN · 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 Share the Coroner’s Inquest findings with Ward E2 staff and highlight the need to review falls risk assessments when bed-bound patients begin sitting out.
Verbatim wording from the response “Following the investigation, Ward E2 shared the findings of the investigation via their Newsletter in June 2016. Please see attached the June ward newsletter for your information (page 2). In August 2016, I can confirm that the findings of the Coroner's Inquest was shared on Ward E2 and attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair. Please see attached the August ward newsletter for your information (page 2).” Source location 2016-0310-Response-by-Stockport-NHS-Trust
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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 The falls risk assessment was completed within six hours of Ward E2 arrival, contrary to the concern that it had not been completed.
Verbatim wording from the response “As confirmed above, the falls risk assessment had been completed within 6 hours of the patient's arrival to Ward E2 and this was in line with Trust policy. This assessment deemed the patient to be at risk of falls and bed rails were in situ. As the falls risk assessment was completed appropriately, this was not deemed to be a care or service delivery problem and therefore was not included within the Patient Safety Investigation report.” Source location 2016-0310-Response-by-Stockport-NHS-Trust
Open published response
26 Jul 2016 Margaret Emily TUCK · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4
Failure to complete nursing sections of post-falls checklists View source Failure to conduct required neurological observations after falls View source Failure to draft falls prevention care plans after identified increased falls risk View source
Inaccurate recording of walking aids in falls risk assessments View source See 1 more concern
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 2
Barts Health NHS Trust
Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.
View source
Barts Health NHS Trust
Implement falls-risk identification and prevention measures, including standardised assessment, high-risk wristbands, direct-observation bays and monthly falls-reduction monitoring.
View source
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AI-generated summary
Margaret Emily TUCK · 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
Margaret Emily Tuck, who had multiple myeloma, fell at home on 13 October 2015 and again in hospital on 15 October 2015. The report identified concerns about the absence of a falls prevention care plan, unclear nursing responsibility, incomplete post-fall documentation, missing neurological observations, delays in recognising possible bleeding and informing the consultant, and shortcomings in incident reporting and the hospital investigation. The inquest jury determined that her death was caused by a combination of accident and illness.
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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 complete nursing sections of post-falls checklists
Wider context from the report “3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed .
The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total.
In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after.
The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this.
” Source location Margaret Emily TUCK · 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 conduct required neurological observations after falls
Wider context from the report “3. After her fall, Mrs Tuck was seen by a junior doctor who examined her thoroughly and filled in the medical portion of the post falls checklist. However, the nursing aspect of this form was never completed.
The FY1 had wanted a neurological observation to be undertaken in addition to the protocol neurological observations of every 30 minutes, but her note was not wholly clear, and could have been interpreted as seeking only one neurological observation in total.
In fact, no neurological observations at all were conducted on the day that Mrs Tuck fell, nor the day after .
The FY1 doctor had wanted to speak to the primary nurse before leaving the bedside, but had been unable to find her. The twin nursing failures of documentation and observation might have been avoided if such a conversation had been mandatory, and there had been a simple way of achieving this.
” Source location Margaret Emily TUCK · 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 draft falls prevention care plans after identified increased falls risk
Wider context from the report “1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted .
And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs Tuck was described on the risk assessment as having no walking aids. In fact, she had a Zimmer frame, and it was while reaching for this Zimmer frame that she fell on the acute admissions unit.
” Source location Margaret Emily TUCK · 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 Inaccurate recording of walking aids in falls risk assessments
Wider context from the report “1. Although a falls risk assessment was conducted upon Margaret Tuck’s admission to hospital, when it demonstrated an increased risk of falling no falls prevention care plan was drafted.
And, whilst most of the preventative measures that would have been detailed on such a care plan were implemented in any event, Mrs Tuck was described on the risk assessment as having no walking aids. In fact, she had a Zimmer frame , and it was while reaching for this Zimmer frame that she fell on the acute admissions unit.
” Source location Margaret Emily TUCK · 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 Deliver multidisciplinary training on falls prevention and post-falls care, with regular assessment of planned and delivered care.
Verbatim wording from the response “3. Our Nurse Educator has been instrumental in setting up and delivering a new multi-disciplinary training programme around important issues, that includes falls prevention awareness and post falls care. As part of the Band 7 role regular assessment during the shift of care planned and delivered, is undertaken. All of our medical staff, including FY1’s, are invited to participate. Falls prevention and awareness is also included in the FY1 mandatory education programme. With the increased presence of Band 6 and 7 nurses on each shift all the clinical staff now have a first contact who they can handover important issues to, even when the named nurse is not on the ward. There are now four multidisciplinary board / handover meetings per 24-hours and these are focussed around patient safety and handover.” Source location 2016-0273-Response-by-Barths-Health-NHS-Trust
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 falls-risk identification and prevention measures, including standardised assessment, high-risk wristbands, direct-observation bays and monthly falls-reduction monitoring.
Verbatim wording from the response “1. The Hospital has undertaken a major piece of work to ensure vulnerable patients are identified and cared for, ensuring their risk of falling is minimised. A falls working group meets monthly, with each clinical area having to present their incidence of falls and work in progress around reduction of these incidents. On the AAU (representative of most clinical areas) all patients are assessed using the Trust falls assessment paperwork (which has been newly amalgamated into a nursing documentation admissions booklet), and any patient identified as a high risk, is then issued with a brightly coloured wrist band with the words ‘HIGH RISK OF FALLS’ printed on it. This signals to all staff, whether regular or agency, that this patient is at risk. All our high risk patients are now under within a bay that allows direct observation by nurses at the nurses’ station.” Source location 2016-0273-Response-by-Barths-Health-NHS-Trust
Open published response
10 May 2016 Christine Valerie STREET · Prevention of Future Deaths report Brighton and Hove
View report summary
Concerns raised 1
Failure to complete admission and fall documentation View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
University Hospitals Sussex 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. 4
University Hospitals Sussex NHS Foundation Trust
Follow up poor documentation with nursing and medical staff.
View source
University Hospitals Sussex NHS Foundation Trust
Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.
View source
University Hospitals Sussex NHS Foundation Trust
Organise a monthly neurosurgical records audit to improve documentation quality.
View source
University Hospitals Sussex NHS Foundation Trust
Conduct senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.
View source See 1 more action
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AI-generated summary
Christine Valerie STREET · 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
Christine Valerie STREET was admitted to hospital with an aggressive brain tumour causing disorientation, confusion, left-sided weakness and a risk of falling. On 11 September 2015, she was found unattended on a toilet floor after an unwitnessed fall, sustaining a minor head injury that accelerated her deterioration and the timing of her death. The report raised concerns about incomplete documentation, failures to follow observation procedures, the use and training of bank staff, and flawed recognition and management of the dying patient.
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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 admission and fall documentation
Wider context from the report “(1) Documentation with regard to the admission document (which was not completed) and the doctors pro forma to document the fall on the 11th September 2015 (was not completed) . The lack of these documents did not affect the outcome, but it is bad practice that they were not completed and placed with Mrs. Street’s notes.
” Source location Christine Valerie STREET · 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 Follow up poor documentation with nursing and medical staff.
Verbatim wording from the response “I am aware that the quality of documentation for Mrs Street was poor in several respects and this has been followed up with both nursing and medical staff. The staff had recognised that Mrs Street was at high risk of falls, and had intended her to have constant attention knowing that she lacked capacity to comprehend her risk of falling as a result of the tumour. It appears that the ward nurses had mistakenly thought that the ‘care record for patient requiring specialising’, which was available as an appendix to the Trust’s ‘policy for the observation of adult patients with mental health problems’, was not intended for use when caring for a patient who was suffering not from a mental illness but from a specific neurological condition - in this instance, a brain tumour. Rapid action was taken when this came to light, to correct their understanding.” Source location 2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff through weekly communications to follow observation policy, use the one-to-one care pathway and document care comprehensively and contemporaneously.
Verbatim wording from the response “It is particularly disappointing that Mrs Street was injured in a fall as this Trust has worked very hard indeed over several years to implement an active falls prevention programme. As a result the Trust has one of the lowest rates of inpatient falls of any acute Trust in the country. Nevertheless, in her weekly message to staff, the Chief Executive has” Source location 2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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 Organise a monthly neurosurgical records audit to improve documentation quality.
Verbatim wording from the response “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.” Source location 2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
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 senior-nurse records spot checks, remedy shortcomings and educate staff on improving records.
Verbatim wording from the response “In order to improve the quality of documentation, the neurosurgeons have organised a monthly records audit. Senior nurses have also been performing spot checks of records and taking action to remedy any shortcomings identified, as well as educating those individuals concerned about how to improve the quality of their records.” Source location 2016-0177-Response-by-Brighton-and-Sussex-University-Hospitals-NHS-Trust
Open published response
10 Dec 2015 Elsie Marjorie Brown · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 6
Failure to report falls View source Failure to record falls View source Failure to hand over falls View source
Lack of falls risk assessments View source Lack of clarity about staff responsibilities for handing over, recording and reporting falls View source Failure to refer residents to the Falls Team View source See 3 more concerns
This report raised 9 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. 4
Your Health Limited
Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.
View source
Your Health Limited
Alter shift patterns to create overlap for a protected, paid handover.
View source
Your Health Limited
Use a multifactorial falls risk assessment covering nighttime risks.
View source
Your Health Limited
Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.
View source See 1 more action
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AI-generated summary
Elsie Marjorie Brown · 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
Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.
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 report falls
Wider context from the report “6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported , and there was a lack of clarity amongst staff as to where responsibilities for these matters rested.
” Source location Elsie Marjorie Brown · 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 record falls
Wider context from the report “6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested.
” Source location Elsie Marjorie Brown · 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 hand over falls
Wider context from the report “6. Mrs Brown’s fall on 23rd March 2013 was not handed over , nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested.
” Source location Elsie Marjorie Brown · 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 falls risk assessments
Wider context from the report “1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed.
” Source location Elsie Marjorie Brown · 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 clarity about staff responsibilities for handing over, recording and reporting falls
Wider context from the report “6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested .
” Source location Elsie Marjorie Brown · 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 refer residents to the Falls Team
Wider context from the report “3. No referral was made to the Falls Team nor (by Langwith Lodge) to Derbyshire Community Health as regards the question of bed rails.
” Source location Elsie Marjorie Brown · 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 Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.
Verbatim wording from the response “The Company has noted that there was some confusion as to who had overall responsibility when 2 senior staff were on duty and we introduced a staff handover document in September 2015 (attached) to document the daily responsibilities of individual staff on duty, as well as clearly outlining who the senior staff on duty were, and who was ultimately in charge of running the home.” Source location Elsie-Brown-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 Alter shift patterns to create overlap for a protected, paid handover.
Verbatim wording from the response “The Company has always recognised the importance of handovers as part of the daily routine for operating a service that runs 24 hours a day, 365 days a year. We are keen to ensure that the handover is a protected part of the day and is not interrupted in any way. We have consulted with staff and altered their shift patterns with effect from 21st January 2015, to ensure that we have an overlap of shifts which allows for a paid handover to take place to relay information about the people we are provided care and support to. We feel this will formalise the current system and make our handover process more robust.” Source location Elsie-Brown-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 Use a multifactorial falls risk assessment covering nighttime risks.
Verbatim wording from the response “The Company did have corporate documentation in relation to falls risk assessment at the time of the incident. The ‘Multi-factorial falls risk assessment’ (attached) was introduced in 2014. This documentation allows Senior and Managerial staff to assess the likelihood of a resident suffering a fall and includes a section about the risks at night time.” Source location Elsie-Brown-Response
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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 a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.
Verbatim wording from the response “A falls management folder was introduced at Langwith in April 2015, which contains a number of different assessment tools to assist staff in reviewing the safety of a resident who is at risk of falls. This includes a specific bed rail risk assessment and algorithm (attached).” Source location Elsie-Brown-Response
Open published response
11 Nov 2015 David Alan White · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Lack of supervision arrangements for falls and mobilisation risk 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. 5
Barts Health NHS Trust
Include verbal handover of falls-risk patients’ care plans in nursing handover safety briefings.
View source
Barts Health NHS Trust
Review escalation of one-to-one supervision requests and enable out-of-hours site-manager contact for patients at risk of falls or confusion.
View source
Barts Health NHS Trust
Move Ward 9F multidisciplinary meetings earlier to develop falls-risk action plans and communicate overnight deterioration.
View source
Barts Health NHS Trust
Recruit a practice development team to support ward adherence to documentation, risk-assessment and communication protocols.
View source
Barts Health NHS Trust
Provide Falls Lead training to retrain nurses in fall procedures and management.
View source See 2 more actions
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AI-generated summary
David Alan White · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
David Alan White was admitted to hospital with significant pain from arterial vascular disease and later sustained two unwitnessed falls, the second causing fractures to his right hip and shoulder. He underwent emergency surgery and subsequently remained seriously unwell before dying on 26 June 2015. Concerns included the failure to record or act on reported confusion associated with Heparin, lack of supervision despite identified falls risks, and inadequate review and action on nursing records.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of supervision arrangements for falls and mobilisation risk
Wider context from the report “(2) Nursing notes documented a risk of falls/mobilisation and action to be taken, but there was no supervision arrangement in place . One to one care had been in contemplation .
” Source location David Alan White · 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 Include verbal handover of falls-risk patients’ care plans in nursing handover safety briefings.
Verbatim wording from the response “2. The safety briefing during nursing handover is now to include a verbal handover of the care plans for patients assessed as at risk of falls to alert incoming staff members as to the risk and care plan.” Source location 2015-0437-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 escalation of one-to-one supervision requests and enable out-of-hours site-manager contact for patients at risk of falls or confusion.
Verbatim wording from the response “We have reviewed the escalation of our ‘Specials’ requests to Bank Partners so that patients can be appropriately monitored and supervised (one to one) when they are assessed as at risk of falls and/or confused. Site managers can now be contacted out of hours to ensure appropriate management of care.” Source location 2015-0437-Response
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 Move Ward 9F multidisciplinary meetings earlier to develop falls-risk action plans and communicate overnight deterioration.
Verbatim wording from the response “3. Multidisciplinary Team meetings on Ward 9F have now been changed to earlier in the day to discuss patients and make effective action plans for patient at risk of falls. This meeting consists of medical/surgical teams, physiotherapy, Occupational Therapists and the Ward Nurse in charge and includes a medical handover to ensure communication of any deterioration overnight that could influence risk of falls, such as increased confusion.” Source location 2015-0437-Response
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 Recruit a practice development team to support ward adherence to documentation, risk-assessment and communication protocols.
Verbatim wording from the response “A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.” Source location 2015-0437-Response
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 Provide Falls Lead training to retrain nurses in fall procedures and management.
Verbatim wording from the response “A practice development team has been recruited to support ward staff in adhering to ward protocols and procedures including documentation, assessment of risks and communication. We also have facilitated training from the ‘Falls Lead’ for the Trust to re-train nurses regarding the fall procedure and management and this took place on 29 June 2015.” Source location 2015-0437-Response
Open published response
26 Oct 2015 Allan Richard Beasley · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 5
Lack of staff awareness of the Falls Prevention Policy View source Failure to escalate falls to appropriate senior staff View source Failure to complete the falls tracker View source
Failure to complete the falls monthly log daily View source Failure to correctly record falls View source See 2 more concerns
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
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
Allan Richard Beasley · 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
Allan Richard Beasley, who had vascular dementia, was admitted to a care home after he could no longer manage at home and experienced multiple falls. Following a further fall, he was diagnosed with cervical spine fractures, developed a chest infection, deteriorated and died. Concerns included inadequate falls-risk assessment, failures to record and escalate falls, inaccurate observation records, and incomplete monitoring and review.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of staff awareness of the Falls Prevention Policy
Wider context from the report “(1) Staff were unaware of the Home’s Falls Prevention Policy . This meant staff failed to correctly record falls and escalate to appropriate senior staff.
” Source location Allan Richard Beasley · 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 escalate falls to appropriate senior staff
Wider context from the report “(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff .
” Source location Allan Richard Beasley · 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 the falls tracker
Wider context from the report “(7) The falls tracker was not completed for Mr Beasley.
” Source location Allan Richard Beasley · 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 the falls monthly log daily
Wider context from the report “(2) The falls monthly log was not completed on a daily basis as it should have been . The log was not completed for June as staff were too busy . This resulted in trends being missed and staff being unaware of the frequency of Mr Beasley’s falls.
” Source location Allan Richard Beasley · 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 correctly record falls
Wider context from the report “(1) Staff were unaware of the Home’s Falls Prevention Policy. This meant staff failed to correctly record falls and escalate to appropriate senior staff.
” Source location Allan Richard Beasley · Prevention of Future Deaths report
Open source report
3 Sep 2015 May Hall · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2
Lack of staff awareness of the policy for reporting falls View source Failure to obtain staff confirmation of receipt of fall-response training 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
May Hall · 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
May Hall fell twice during the night of 11/12 April 2015, banging her head on both occasions, and later died from a subdural haematoma. Staff at Bourne House indicated that they were not aware of a policy for reporting falls or calling an ambulance or emergency doctor, and the report identified a need for clear, regularly reviewed staff training on responding to falls.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Lack of staff awareness of the policy for reporting falls
Wider context from the report “The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor.
There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed.
” Source location May Hall · 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 obtain staff confirmation of receipt of fall-response training
Wider context from the report “The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor.
There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed.
” Source location May Hall · Prevention of Future Deaths report
Open source report
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.