Concerns raised 1
Failure to keep adequate records of falls care View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Doncaster and Bassetlaw Teaching Hospitals NHS Foundation Trust
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AI-generated summary
Walter Colin HORTON · 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
Walter Colin HORTON, an 88-year-old male, died in a nursing home on 10 January 2025. The recorded causes included sepsis and an advanced sacral pressure sore, with ischaemic heart disease also noted. Concerns included poor record keeping and failures to understand or follow aseptic techniques and cleanliness when managing wounds, increasing the risk of infection.
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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 keep adequate records of falls care
Wider context from the report “(1) Poor record keeping in regard to key areas of care namely falls and wound management
and handover information on discharge
(2) A failure to understand or to follow use of aseptic techniques and cleanliness when
managing wounds thus increasing the risk of infection.
” Source location Walter Colin HORTON · Prevention of Future Deaths report
Open source report
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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 There is no record or evidence that the patient experienced a fall during admission.
Verbatim wording from the response “• There is no record or evidence of Mr Horton experiencing a fall during his admission.” Source location Response from Doncaster and Bassetlaw Teaching Hospitals NHS FT
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Trust disputes that Mr Horton experienced a fall during admission, stating that no record or evidence of a fall exists.
Verbatim wording from the response “1. Record Keeping - Falls” Source location Response from Doncaster & Bassetlaw NHS Foundation Trust
Open published response
28 Aug 2025 Edwin Everett Milne Price · Prevention of Future Deaths report Somerset
View report summary
Concerns raised 3
Failure to address gaps in the falls risk assessment and management process for patients admitted from care homes View source Failure to complete falls risk assessments within the first 24 hours of ward admission View source Lack of falls risk mitigation measures View source
This report raised 1 other concern. They are not shown here because they do not form part of this recurring concern.
Linked response
Somerset 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. 6
Somerset NHS Foundation Trust
Require falls risk assessments within 12 hours of admission, with weekly or condition-triggered reviews, and display patient risk status at the bedside.
View source
Somerset NHS Foundation Trust
Monitor falls risk assessment compliance through monthly Core Nursing Metrics audits and additional spot audits.
View source
Somerset NHS Foundation Trust
Use an acute medical unit admission checklist to contact families, care homes or community hospitals and gather baseline information for risk mitigation.
View source
Somerset NHS Foundation Trust
Improve Intentional Rounding through role modelling, a patient-centred real-time documentation tool and rollout of the new form across the acute medical unit.
View source
Somerset NHS Foundation Trust
Allocate medical matrons 20% of weekly time to clinical ward work supporting training, high-risk patient identification, ward rounds and safety huddles.
View source
Somerset NHS Foundation Trust
Review reported incidents daily and verify that measures and steps have been taken to mitigate further patient harm.
View source See 3 more actions
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AI-generated summary
Edwin Everett Milne Price · 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
Edwin Everett Milne Price, who lived in a nursing home and required hoisting for transfers, was admitted to hospital with diabetic ketoacidosis and fell out of bed the following day. He sustained a fractured humerus and a retroperitoneal bleed, which was recorded as the cause of his death. The principal concerns were that his falls risk assessment was not completed within 24 hours, relevant information was not obtained from the nursing home, and mitigation measures were not put in place.
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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 address gaps in the falls risk assessment and management process for patients admitted from care homes
Wider context from the report “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward.
2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate.
3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed.
4. The lack of a risk assessment meant that mitigation measures were not in place.
5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death.
6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.
” Source location Edwin Everett Milne Price · 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 falls risk assessments within the first 24 hours of ward admission
Wider context from the report “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward.
2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate.
3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed.
4. The lack of a risk assessment meant that mitigation measures were not in place.
5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death.
6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.
” Source location Edwin Everett Milne Price · 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 mitigation measures
Wider context from the report “1. The falls risk assessment was not completed within the first 24 hours of admission to the ward.
2. Had it been completed, the risk assessment would have involved obtaining information from the nursing home as Mr Price was unable to communicate.
3. A risk assessment would have identified Mr Price’s specific risk of falling out of bed.
4. The lack of a risk assessment meant that mitigation measures were not in place.
5. The lack of mitigation measures made a more than minimal contribution to the extent of Mr Price’s injuries and therefore to his death.
6. No subsequent action has been taken by the ward to address the gaps in the falls risk assessment and management process when patients are admitted from care homes.
” Source location Edwin Everett Milne Price · 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 Require falls risk assessments within 12 hours of admission, with weekly or condition-triggered reviews, and display patient risk status at the bedside.
Verbatim wording from the response “In April 2023 Somerset NHS Foundation Trust (SFT) and Yeovil District Hospital (YDH) merged organisations to become one Somerset NHS Foundation Trust, and there has been a period, ongoing, where there has been alignment of policies and guidance across the new Somerset NHS FT organisation. At the time of Mr Price’s fall, colleagues in YDH were still working to the legacy policy in place which did not have a time frame in which a Falls Risk assessment was to be completed. The legacy Somerset FT policy and the newly merged one organisational Somerset FT policy both state that an individual must have a Falls Risk Assessment within 12 hours of admission to an inpatient ward, and that this is reviewed if the person moves to another inpatient ward / has a fall / their condition changes.” Source location Response from Somerset NHS Foundation 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 Monitor falls risk assessment compliance through monthly Core Nursing Metrics audits and additional spot audits.
Verbatim wording from the response “The Deputy Associate Director of Patient Care (ADPC), Matron and Ward Managers are monitoring compliance with the completion of the falls risk assessments and although these are audited monthly through our Core Nursing Metrics, additional spot audits are also being undertaken. These have shown an increase in compliance, however further strengthening in this area is required to ensure an embedded and sustained process of compliance with the expected 12-hour target.” Source location Response from Somerset NHS Foundation 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 Use an acute medical unit admission checklist to contact families, care homes or community hospitals and gather baseline information for risk mitigation.
Verbatim wording from the response “In response to this incident, our acute medical unit (AMU) has introduced a checklist to be completed on admission which involves contacting the patient’s family, care home or community hospital to gather more detailed information about the patient (see appendix 1). The guidance on the patient’s baseline function and the usual mitigations that are in place in their usual residence to reduce the risk of harm” Source location Response from Somerset NHS Foundation 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 Improve Intentional Rounding through role modelling, a patient-centred real-time documentation tool and rollout of the new form across the acute medical unit.
Verbatim wording from the response “We acknowledge also that an appropriate risk assessment on admission would have assisted us to identify Mr Price’s risk more clearly and put sufficient mitigations in place to reduce the risk of harm to him. In addition to the risk assessment, to help us reduce risk to patients, we use an Intentional Rounding tool to assist with care planning and patient involvement. At a minimum a patient is seen two hourly and engaged with, this is in addition to physical observations. From our recent reviews, including learning from Mr Price’s case, it has become clear that there has been a lack of clarity around the purpose and process associated with the meaningful delivery of Intentional Rounding across the Trust.” Source location Response from Somerset NHS Foundation 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 Allocate medical matrons 20% of weekly time to clinical ward work supporting training, high-risk patient identification, ward rounds and safety huddles.
Verbatim wording from the response “The medical matrons are now working 20% of their time clinically on our wards each week, supporting with training and education and supporting with the identification of our high-risk patients and are leading ward rounds and safety huddles with the ward senior leadership team.” Source location Response from Somerset NHS Foundation 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 Review reported incidents daily and verify that measures and steps have been taken to mitigate further patient harm.
Verbatim wording from the response “We have launched a test of change with a 5 day a week supernumerary role, titled the Quality and Safety Lead Nurse (2 full time posts) within the medical services group, with clear aims, objectives and job planning, this will follow QI methodology and falls will be part of their patient safety remit. The ADPC and Deputy support a daily review of all incidents reported and the matrons will also review and ensure that all measures and steps have been taken to mitigate any further risk of harm for the patients in our care.” Source location Response from Somerset NHS Foundation Trust
Open published response
Concerns raised 2
Failure to put recommended falls prevention equipment in place View source Reluctance to provide adequate resources for falls prevention equipment 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
Patricia Heaviside · 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
Patricia Heaviside, a resident of Howlish Hall Care Home, suffered an unwitnessed fall on 4 October 2024, fractured her left hip, and died on 26 December 2024 as a consequence of the fracture. Concerns included the failure to implement recommended falls-prevention equipment, failures to share relevant information with family and social services, and apparent reluctance to provide adequate resources for falls prevention. The report also raised concerns that no DoLS assessment application appeared to have been made despite her lack of mental capacity and inability to keep herself safe.
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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 put recommended falls prevention equipment in place
Wider context from the report “(1) Despite recommendations for falls prevention equipment being made by the Community Falls Service in August 2023, no falls prevention equipment was put in place by the time of the Deceased’s fall in fall October 2024
(2) Despite the social worker expressing concern about the lack of falls prevention equipment on 27 September 2024, no falls equipment was put in place prior to the Deceased’s fall on 4 October 2024.
” Source location Patricia Heaviside · 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 Reluctance to provide adequate resources for falls prevention equipment
Wider context from the report “(4) On 5 August 2024 (following a fall, but before the more significant fall on 4 October 2024), the Deceased’s family were told by the Deputy Manager of Howlish Hall that the owner of Howlish Hall “probably wouldn’t want to pay for a sensor mat” .
(5) I received evidence that, subsequent to the Deceased’s death, there had been a reluctance on the part of ████████ (who was believed to be the owner of Howlish Hall Care Home) to provide adequate resources for falls prevention equipment .
” Source location Patricia Heaviside · 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 Provide 12 working sensor mats and fall-detection equipment for service users.
Verbatim wording from the response “I hereby enclose testimonies from our ████████
████████ that the building had 12 working sensor mats to prevent falls as opposed to what stated. Moreover, the ████████ has withdrawn her first statement and stated she was mistaken and above this, we are aware that ████████ has tempered with the sensors.” Source location Response from Howlish Hall Care Home
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 Impose registration conditions requiring the provider to safeguard residents from falls, confirm suitable equipment is in place, and update care plans.
Verbatim wording from the response “During the inspection on 2, 3, 9 and 11 July 2025 and subsequent concerns shared with us by Durham County Council, we had significant concerns in relation to falls management at the service. As stated above, we took urgent action to impose conditions on the provider’s registration. One of the conditions included a requirement for the provider to take steps to safeguard people from the risk of falls, including confirmation that appropriate equipment was in situ and service users care plans reflected the level of support and equipment they required to reduce the risks associated with falls.” Source location 2025-0354 Response from Care Quailty Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The report’s claim that sensor mats were not purchased or available is disputed as inaccurate.
Verbatim wording from the response “I hereby enclose testimonies from our ████████
████████ that the building had 12 working sensor mats to prevent falls as opposed to what stated. Moreover, the ████████ has withdrawn her first statement and stated she was mistaken and above this, we are aware that ████████ has tempered with the sensors.” Source location Response from Howlish Hall Care Home
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing fall sensors and an urgent calling system were considered sufficient to protect service users.
Verbatim wording from the response “I hereby enclose testimonies from our ████████
████████ that the building had 12 working sensor mats to prevent falls as opposed to what stated. Moreover, the ████████ has withdrawn her first statement and stated she was mistaken and above this, we are aware that ████████ has tempered with the sensors.” Source location Response from Howlish Hall Care Home
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Responsibility for sourcing and implementing recommended falls prevention equipment rests with care home management, not the Council.
Verbatim wording from the response “It is important to clarify that Durham County Council was not directly informed of the recommendations made by the County Durham and Darlington NHS Foundation Trust (CDDFT) Community Falls Service. In accordance with standard protocol, such recommendations are communicated solely to the care home, which retains full responsibility for reviewing, actioning, and implementing the advised measures.” Source location Response from Durham County Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Council was not aware of evidence that the owner specifically refused resources for falls prevention equipment, and observed equipment installed in several bedrooms.
Verbatim wording from the response “(5) I received evidence that, subsequent to the Deceased’s death, there had been a reluctance on the part of ████████ (who was believed to be the owner of Howlish Hall Care Home) to provide adequate resources for falls prevention equipment.” Source location Response from Durham County Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The provider is best placed to address whether sensor mats should have been supplied for an individual's assessed needs.
Verbatim wording from the response “4. On 5 August 2024 (following a fall, but before the more significant fall on 4 October 2024), the Deceased’s family were told by the Deputy Manager of Howlish Hall that the owner of Howlish Hall “probably wouldn’t want to pay for a sensor mat”.” Source location 2025-0354 Response from Care Quailty Commission
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Sensor mats provide an early warning enabling swift responses but do not physically prevent falls.
Verbatim wording from the response “CQC expects care providers to follow the NICE guidelines on falls management (https://www.nice.org.uk/guidance/ng249/chapter/Recommendations#interventions-to-reduce-the-risk-of-falls). We expect providers to take a multi-factorial approach to falls management which includes measures such as conducting medication reviews, encouraging the person to remain physically active and removing hazards from the environment. Whilst sensor mats are useful as an early warning system that alerts care staff to potential falls or movements to enable swift responses to prevent injuries, they do not physically prevent a person having a fall.” Source location 2025-0354 Response from Care Quailty Commission
Open published response
Concerns raised 4
Failure to complete a Datix report following an inpatient fall View source Failure to complete a falls assessment within six hours of transfer View source Failure to put falls prevention measures in place following the first falls assessment View source
Failure to document falls prevention measures at the first falls assessment View source See 1 more concern
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
the Rotherham NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
the Rotherham NHS Foundation Trust
Add incident-reporting prompts to the nurse-in-charge checklist to identify and escalate outstanding Datix reports.
View source
the Rotherham NHS Foundation Trust
Implement a standardised safety-huddle log with falls-prevention prompts and measure compliance and effectiveness during implementation.
View source
the Rotherham NHS Foundation Trust
Implement a real-time Meditech dashboard showing outstanding and completed risk assessments for nurse-in-charge oversight.
View source
the Rotherham NHS Foundation Trust
Refresh risk assessments on transfer to a new ward so staff complete them from the patient’s current presentation.
View source
the Rotherham NHS Foundation Trust
Complete Ward B4’s initial Exemplar Accreditation assessment, including handover and falls-assessment review, in October 2025.
View source
the Rotherham NHS Foundation Trust
Make falls-prevention documentation mandatory in risk assessments and audit compliance through Tendable.
View source
the Rotherham NHS Foundation Trust
Recruit and commence a falls lead practitioner to drive Trust-wide falls-prevention improvements, audit clinical effectiveness and identify further quality-improvement work.
View source
the Rotherham NHS Foundation Trust
Include falls prevention within the Exemplar Accreditation programme and continuously measure ward performance.
View source See 5 more actions
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AI-generated summary
Hazel Gambles · 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
Hazel Gambles was admitted to hospital after a fall at home and was later found to have sustained a brain bleed in an unwitnessed in-patient fall. She died on 27 January 2025, and the report states that the head injury more than minimally contributed to her death. The principal concerns were failures to complete and implement falls assessments and prevention measures, delay in medical review, inadequate communication with her family, failure to report and investigate the fall, and omission of the fall from the discharge letter.
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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 a Datix report following an inpatient fall
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping.
” Source location Hazel Gambles · 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 a falls assessment within six hours of transfer
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward , by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping.
” Source location Hazel Gambles · 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 put falls prevention measures in place following the first falls assessment
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping.
” Source location Hazel Gambles · 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 document falls prevention measures at the first falls assessment
Wider context from the report “There are several areas of concern around failures in documentation and failures to follow Trust policy, namely:
1. Lying and standing Blood Pressure was not recorded on admission.
2. There was no documentation of any falls prevention measures at the time of the first falls assessment.
3. There is no evidence of falls prevention measures being put in place following the first falls assessment.
4. There was no falls assessment done at the time of transfer to ward B4. There should have been a falls assessment within six hours of transfer but that did not happen. The assessment took place some 23 hours after admission to the ward, by which time Mrs Gambles had already fallen.
5. Following the in-patient fall there was a delay of over 5 hours before a medical review took place. The note recording the request for medical review is not timed.
6. There was no discussion with Mrs Gambles' family explaining the findings of the CT scan and they were not told about the bleed on the brain.
7. No Datix report was done following the in-patient fall leading to a delay in investigation.
8. The in-patient fall is not mentioned on the Discharge letter.
I am concerned that these failures suggest a lack of awareness of, and lack of compliance with, the Trust’s processes on falls assessment and record keeping.
” Source location Hazel Gambles · 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 Add incident-reporting prompts to the nurse-in-charge checklist to identify and escalate outstanding Datix reports.
Verbatim wording from the response “The nurse in charge checklist now asks the question “has there been any incidents? Have these been recorded via Datix?”. This gives an opportunity for the senior team to consider whether there are any outstanding incident reports and if so, ensure that these are reported at the earliest opportunity.” Source location Response from Rotherham NHS Foundation 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 a standardised safety-huddle log with falls-prevention prompts and measure compliance and effectiveness during implementation.
Verbatim wording from the response “The Trust has also now implemented a standardised safety huddle log. Please find this attached at Exhibit 2. Within this, there is a section in relation to falls and specific prompts to ask:” Source location Response from Rotherham NHS Foundation 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 a real-time Meditech dashboard showing outstanding and completed risk assessments for nurse-in-charge oversight.
Verbatim wording from the response “Since Mrs Gambles’ admission, we have now implemented an overview dashboard within the Meditech system (the Trust’s medical records system). This is an electronic dashboard and shows in real time which risk assessments have been completed and which are still outstanding for each patient. The use of this board throughout the nurse in charge shift means that they now direct staff when assessments haven't been completed and it is much clearer to identify when risk assessments are overdue or have not taken place.” Source location Response from Rotherham NHS Foundation 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 Refresh risk assessments on transfer to a new ward so staff complete them from the patient’s current presentation.
Verbatim wording from the response “Risk assessments also now refresh on transfer to a new ward so that there is less risk of a staff member copying the previous ward assessments. On transfer to a new ward, the staff member will be presented with a completely blank risk assessment which will prompt them to fill in the assessment from scratch based on the patient’s current presentation.” Source location Response from Rotherham NHS Foundation 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 Complete Ward B4’s initial Exemplar Accreditation assessment, including handover and falls-assessment review, in October 2025.
Verbatim wording from the response “Ward B4 was initially set up as a winter pressures ward, but now has a substantive leadership team. As it is a new ward, it is in its baseline data gathering year and has not had an initial accreditation (using the Exemplar Accreditation Programme), however this will happen in October 2025 once there is a year’s worth of data. This will include handover and falls assessments and any non-compliance will lead to clear improvement actions.” Source location Response from Rotherham NHS Foundation 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 Make falls-prevention documentation mandatory in risk assessments and audit compliance through Tendable.
Verbatim wording from the response “At the time of Mrs Gambles’ admission, the falls prevention measures part of the risk assessment was not a mandatory field and so there was a risk that this would be missed. Since Mrs Gambles’ death, this has now been changed to a mandatory field within the risk assessment. This means that nursing staff are unable to progress with documentation until they have completed the entry, and so it should be clear as to what falls prevention measures are required for each individual patient. Compliance with this is audited as part of the Tendable audit. The Tendable falls inspection overall outcome score from February 2025 to August 2025 shows that overall compliance has risen from 78% in February 2025 to 98% in August 2025.” Source location Response from Rotherham NHS Foundation 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 Recruit and commence a falls lead practitioner to drive Trust-wide falls-prevention improvements, audit clinical effectiveness and identify further quality-improvement work.
Verbatim wording from the response “In relation to falls, the Trust has also successfully recruited a falls lead practitioner. This practitioner is due to commence next month (September 2025). The falls lead will have a responsibility to drive improvements in the prevention and treatment of all falls within the Trust. Part of their role will be looking at clinical effectiveness and to look at anything which may fall outside of the falls audit. They will also be reviewing the national falls audit and considering where further improvements need to be made.” Source location Response from Rotherham NHS Foundation 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 Include falls prevention within the Exemplar Accreditation programme and continuously measure ward performance.
Verbatim wording from the response “within the Trust’s Exemplar Accreditation programme which is designed around the CQC key lines of enquiry to ensure the quality of care delivered to patients within a ward environment. Each area is measured continuously.” Source location Response from Rotherham NHS Foundation Trust
Open published response
17 Jun 2025 Sonia Grace SORE · Prevention of Future Deaths report Suffolk
View report summary
Concerns raised 1
Failure to implement identified mitigation measures 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. 6
Maven Healthcare
Complete a companywide review of residents’ risk assessments, care plans, risk-mitigation actions and communication records.
View source
Maven Healthcare
Deliver mandatory falls-prevention, regulatory-responsibility and care-plan-adherence refresher training, with reflective practice for registered nurses.
View source
Maven Healthcare
Introduce daily huddles, clinical risk meetings, staff meetings, a weekly clinical risk register and regular management validation visits.
View source
Maven Healthcare
Implement electronic PCS sign-off for high-risk plans and critical fall-risk measures.
View source
Maven Healthcare
Review safe-bedrail and falls-risk policies and procedures to reflect new systems, processes and initiatives.
View source
Maven Healthcare
Cascade revised safe-bedrail and falls-risk policies and procedures across the company.
View source See 3 more actions
×
AI-generated summary
Sonia Grace SORE · 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
Sonia Grace SORE, who had significant mobility difficulties and was assessed as at risk of falling from her bed, fell from her bed on 14 October 2023 and again on 20 October 2023. She later developed a subdural haematoma, deteriorated, and died on 8 November 2023. The substantive concern was that staff at North Court Care Home repeatedly failed to implement identified risk-mitigation measures, including securing the right-hand bed rail, suggesting a possible wider cultural problem.
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 implement identified mitigation measures
Wider context from the report “During the course of the evidence it was apparent that within North Court Care Home there was a less than diligent focus on risk assessment and mitigation.
Despite risks being assessed, and mitigation measures identified, staff would regularly fail to implement the latter . In Mrs. SORE’s case this included the failure to secure the right hand side bed rail as identified in numerous risk assessments relating to mitigating her risk of falling from the bed. The evidence indicated that this applied in relation to the actions of multiple staff at the care home, not just a few , giving rise to the concern that this was a cultural problem at North Court Care Home
” Source location Sonia Grace SORE · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a companywide review of residents’ risk assessments, care plans, risk-mitigation actions and communication records.
Verbatim wording from the response “Risk Assessment Compliance Audits – A full review of each resident’s individual risk assessments was completed which included the review of the associated care plan and supporting supplementary records. The review not only focused on the identification of key risks but also on the actions taken to minimize risk and how key information was communicated to the staff team and each residents” Source location Response from Maven Healthcare
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 Deliver mandatory falls-prevention, regulatory-responsibility and care-plan-adherence refresher training, with reflective practice for registered nurses.
Verbatim wording from the response “Enhanced Staff Training - Mandatory refresher training in relation to falls prevention, regulatory responsibilities, and care plan adherence has been delivered. Reflective practice has been completed with the staff members who are registered with the Nursing and Midwifery Council to reinforce their understanding of their professional competence and responsibilities in alignment with the Professional Code of Conduct” Source location Response from Maven Healthcare
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Introduce daily huddles, clinical risk meetings, staff meetings, a weekly clinical risk register and regular management validation visits.
Verbatim wording from the response “Communication – The communication systems used within the service have been reviewed and robust systems such as daily huddles, Clinical Risk meetings, general staff meetings have been introduced to ensure information is safely communicated to all staff members. In addition, a weekly Clinical Risk Register is in place which includes the use of bed rails and prevalence of falls. The Clinical Risk Register is reviewed weekly at a minimum and shared with the Regional Manager who completes a visit to the service to validate the data. As a company additional support is provided by the Operational Team who also visit the service at a minimum of monthly to validate and monitor the adherence to internal governance systems and external regulations.” Source location Response from Maven Healthcare
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 Implement electronic PCS sign-off for high-risk plans and critical fall-risk measures.
Verbatim wording from the response “• New 'Sign-Off System for High-Risk Plans has been implemented in relation to identified critical fall risk measures. This system is called PCS which is an electronic care planning platform.” Source location Response from Maven Healthcare
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 Review safe-bedrail and falls-risk policies and procedures to reflect new systems, processes and initiatives.
Verbatim wording from the response “• Company Policies and Procedures in relation to the Safe Use of Bed Rails and Falls Risk Management have been reviewed to ensure all company Policies and Procedures are reflective of all new systems, processes and initiatives. Changes to the Policies and Procedures will be cascaded across the company.” Source location Response from Maven Healthcare
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 Cascade revised safe-bedrail and falls-risk policies and procedures across the company.
Verbatim wording from the response “• Company Policies and Procedures in relation to the Safe Use of Bed Rails and Falls Risk Management have been reviewed to ensure all company Policies and Procedures are reflective of all new systems, processes and initiatives. Changes to the Policies and Procedures will be cascaded across the company.” Source location Response from Maven Healthcare
Open published response
13 Jun 2025 Valerie HILL · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3
Failure of falls-management materials to address preventive risk identification, assessment and documentation View source Lack of an available Falls Prevention Strategy or Policy for resident falls-risk assessments View source Failure to analyse, assess and communicate falls notifications to inform ongoing risk assessment and mitigation View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Merthyr Tydfil County Borough Council
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
Merthyr Tydfil County Borough Council
Implement staff guidance for preventing and managing falls in residential care homes.
View source
Merthyr Tydfil County Borough Council
Implement a multifactorial falls risk assessment for relevant adult services users.
View source
Merthyr Tydfil County Borough Council
Implement a post-fall summary process to review individual falls and identify ongoing risks.
View source
Merthyr Tydfil County Borough Council
Implement a new moving and handling risk assessment form for residential care occupants.
View source See 1 more action
×
AI-generated summary
Valerie HILL · 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
Valerie HILL died from pneumonia following a fall that caused a periprosthetic femur fracture, with COPD and frailty of old age contributing. She had remained on the floor for over 14 hours awaiting an ambulance after falling at Ty Bargoed Care Home. The report raised concerns about the identification, documentation and mitigation of falls risks, staff training, completion and oversight of risk assessments, and ambulance handover and patient-flow systems.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure of falls-management materials to address preventive risk identification, assessment and documentation
Wider context from the report “(3) the material filed with me focuses upon how to move a fallen person/their management post fall, not the identification /assessment/documentation of risk in order to prevent/mitigate the happening of such events .
” Source location Valerie HILL · 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 available Falls Prevention Strategy or Policy for resident falls-risk assessments
Wider context from the report “(5) Your Exhibit KL1 at page 27 references regard being had to Falls Prevention Strategy or Policy – I have received no evidence that MTCBC have such available and in place to inform Care Home’s and their staff in preparation for the completion of a resident’s falls risk assessment
” Source location Valerie HILL · 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 analyse, assess and communicate falls notifications to inform ongoing risk assessment and mitigation
Wider context from the report “(6) Whilst I am reassured to an extent in relation to the management and retention of incident & risk assessment documentation created in Ty Bargoed moving forwards, I am unclear as to what action, if any, MTCBC’s Health and Safety Unit take upon receipt of falls notifications (as described in ████████’s evidence) and what, if any, analysis/assessment/communication is undertaken in respect of the same with a view to supplementing the ongoing falls risk assessment and collateral mitigating measures .
” Source location Valerie HILL · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement staff guidance for preventing and managing falls in residential care homes.
Verbatim wording from the response “5. Consequent upon the concerns of HM Senior Coroner, however, a number of new documents have now been drafted and have recently been implemented by Merthyr Council in the context of addressing these concerns, moving forwards.” Source location Response from Merthyr Tydfil County Borough Council
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 a multifactorial falls risk assessment for relevant adult services users.
Verbatim wording from the response “7. A copy of the latest version of this Prevention and Management of Falls guidance document for staff is attached to this witness statement marked “KL 6”.” Source location Response from Merthyr Tydfil County Borough Council
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 a post-fall summary process to review individual falls and identify ongoing risks.
Verbatim wording from the response “9. Additionally, a Post Fall Summary document has also been developed as a means of review and evaluation of any falls sustained by care home residents, to further understand and review risk in general on an ongoing basis. A copy of this document is attached to this witness statement marked “KL 8”.” Source location Response from Merthyr Tydfil County Borough Council
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 a new moving and handling risk assessment form for residential care occupants.
Verbatim wording from the response “11. As part of this process, a new Moving and Handling Risk Assessment Form has also been developed and a copy of that new form is attached to this witness statement as “KL 9”. It is anticipated that this new approach to the moving and handling plan will ensure that this document is a “living document” – that is to say – it is continually informed and reviewed by” Source location Response from Merthyr Tydfil County Borough Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adult Social Care is responsible for general falls risk through individual care and moving-and-handling plans; Health and Safety addresses environmental or particular risks.
Verbatim wording from the response “24. The (ever present) falls risk associated with elderly persons in a care home setting is primarily the focus of Adult Social Care and needs to be addressed via individual care plans (through Social Services) and moving and handling plans (developed on site – see above), based on appropriate risk assessments. The health and safety team’s principal involvement should be to ensure that if there is an underlying environmental or other particular risk, it is picked up and addressed. Despite the best staff and care, there will be falls from time to time – this is a recognised feature of the care of older and frail persons.” Source location Response from Merthyr Tydfil County Borough Council
Open published response
27 May 2025 Keith Ineson · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2
Failure to conduct an appropriate post-fall injury assessment View source Failure to record all post-fall observation scores View source
Linked response
Barchester Healthcare Limited
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Barchester Healthcare Limited
Implement the EnabLE digital care-planning system for scheduled post-fall observations, alerts and point-of-care recording.
View source
Barchester Healthcare Limited
Deliver targeted training and supervision on post-fall documentation, escalation, observation recording and lessons learned from the incident.
View source
Barchester Healthcare Limited
Complete NEWS2, RESTORE and sepsis training and themed supervision for recognising deteriorating residents.
View source
Barchester Healthcare Limited
Review the falls policy with clinical staff and reinforce procedures for responding and escalating after falls.
View source
Barchester Healthcare Limited
Deliver moving-and-handling refresher training covering post-fall procedures and techniques to mitigate falls.
View source
Barchester Healthcare Limited
Provide documentation prompt sheets to support completion of post-fall records.
View source
Barchester Healthcare Limited
Continue EnabLE drop-in support, documentation audits and remote monitoring for adherence and learning needs.
View source
Barchester Healthcare Limited
Complete induction, including NEWS2 training, for three new bank nurses.
View source See 5 more actions
×
AI-generated summary
Keith Ineson · 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
Keith Ineson, a resident at Glenroyd Care Home, suffered an unwitnessed fall on 26 April 2024 and was subsequently treated for a fractured hip. Following surgery, he suffered a choking episode, developed aspiration pneumonia and died at Blackpool Victoria Hospital on 6 May 2024. The principal concern was that observation scores taken after the fall were not all recorded, leaving gaps in the information available to assess whether escalation to medical services was needed and creating a risk of further death.
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 conduct an appropriate post-fall injury assessment
Wider context from the report “Following the fall on 26 April 2024, I found that the senior carer who checked Mr Ineson for signs of injury had conducted an inappropriate assessment .
” Source location Keith Ineson · 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 all post-fall observation scores
Wider context from the report “It was noted in the evidence, that the observation scores taken for Mr Ineson following his fall had not all been recorded in Mr Ineson’s care notes . This left a gap in the evidence as to reviewing the need for escalation to medical services after the fall.
I received from witnesses who gave evidence before me, helpful assistance concerning several issues about learning and changes that had been made following Mr Ineson’s death.
I could not identify changes to the record keeping system though, and as such found that the issue around the absence of recording observation scores following a fall gave rise to a risk of further death . This was because the record keeping was inaccurate, contained gaps in the information , and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” Source location Keith Ineson · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement the EnabLE digital care-planning system for scheduled post-fall observations, alerts and point-of-care recording.
Verbatim wording from the response “The Learned Coroner will recall that in addition to the actions undertaken which were set out in the action plan submitted prior to the inquest, ████████, the Registered Manager of Glenroyd Care Home explained that Barchester has implemented a new digital care planning system called EnabLE which provides Barchester healthcare services with the ability to set up planned post fall interaction scheduled observations that can be recorded at the point of care to ensure accuracy and eliminate the risk of absent recordings. The system is relatively new, and we have completed some additional training with staff and themed supervisions, to ensure they know how to add to the scheduled observations. We are auditing the use of the systems – see below.” Source location Response from Barchester Healthcare Ltd
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 Deliver targeted training and supervision on post-fall documentation, escalation, observation recording and lessons learned from the incident.
Verbatim wording from the response “Following the Inquest, Barchester revisited the issue of recording of all resident interactions and observations to ensure this is undertaken clearly, consistently and contemporaneously. We acknowledge that there was a need to improve the accuracy and regularity of record keeping. We have taken appropriate action in relation to training and technology to ensure that all interactions with patients are recorded.” Source location Response from Barchester Healthcare Ltd
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 Complete NEWS2, RESTORE and sepsis training and themed supervision for recognising deteriorating residents.
Verbatim wording from the response “Our new digital system limits any opportunities missing entries in relation to observations. Our observations are recorded on the digital system in a NEWS2 (National Early Warning Score) observation record, rather than manually written. The training for this has been completed in the home, and we also have oversight by the regional Clinical Development Nurse who supports all her homes monthly and looks at the system to make sure everything is recorded as it should be.” Source location Response from Barchester Healthcare Ltd
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 Review the falls policy with clinical staff and reinforce procedures for responding and escalating after falls.
Verbatim wording from the response “Further, lessons learned as stated above, include correct moving & handling techniques. The falls policy has been reviewed by all clinical staff to ensure that everyone is aware of the policy and procedure following a fall (supported by the NEWS2 and RESTORE training above) therefore any need for escalation to medical services following a patient’s fall will be abundantly clear. The prompt sheets and guides created give an oversight of completion and can be checked by management, thereby mitigating the risk of the recording of inaccurate and irregular observations.” Source location Response from Barchester Healthcare Ltd
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 Deliver moving-and-handling refresher training covering post-fall procedures and techniques to mitigate falls.
Verbatim wording from the response “In addition, the members of staff involved in the incident attended a Moving & Handling refresher training day with an Operational Trainer on 3rd June 2024. The moving and” Source location Response from Barchester Healthcare Ltd
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 documentation prompt sheets to support completion of post-fall records.
Verbatim wording from the response “In addition to the training programme and support staff are provided with an added prompt sheet to support them in the completion of documentation. This is part of a “belt and braces” approach to training.” Source location Response from Barchester Healthcare Ltd
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 Continue EnabLE drop-in support, documentation audits and remote monitoring for adherence and learning needs.
Verbatim wording from the response “As part of the continuing programme of learning the region’s EnabLE champion who supports the home with EnabLE will continue with the provision of drop-in sessions, documentation audit and will continue to monitor remotely for any trends in learning needed around the digital system to ensure adherence to the actions triggered in the new system.” Source location Response from Barchester Healthcare Ltd
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 Complete induction, including NEWS2 training, for three new bank nurses.
Verbatim wording from the response “The training statistics for the home are 100% for NEWS2 in the home which ensures the accuracy, frequency and consistency of recording observations. Every Nurse, Senior carer and Care Practitioner has completed NEWS2 training, and three new bank nurses are in the process of completing their induction of which NEWS2 is part of the process. All NEWS2 training is completed on induction into the home, we have checked the recorded dates of NEWS2 training, and the dates have been recorded in the Learning Management system.” Source location Response from Barchester Healthcare Ltd
Open published response
26 May 2025 Sarah Kathleen Hill · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 2
Failure to undertake and evidence appropriate falls risk assessments View source Failure to report falls or collapses on the ward 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
North Cumbria Integrated Care 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
North Cumbria Integrated Care NHS Foundation Trust
Complete an urgent assurance check of falls documentation and current AMU patient monitoring.
View source
North Cumbria Integrated Care NHS Foundation Trust
Review ward falls assurance evidence against the Trust-wide Falls Improvement Plan and ward SMART plans.
View source
North Cumbria Integrated Care NHS Foundation Trust
Revise the FRAMP policy to mandate reassessment after sedation, deterioration or procedures and reinforce prompt documentation.
View source
North Cumbria Integrated Care NHS Foundation Trust
Deliver refresher incident-reporting training to AMU nursing staff covering falls, collapses, unwitnessed incidents and reporting thresholds.
View source See 1 more action
×
AI-generated summary
Sarah Kathleen Hill · 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
Sarah Kathleen Hill was admitted for an elective ERCP to remove gallstones and developed worsening pancreatitis, perforation, multi-organ failure and cardiac arrest before dying in the early hours of 8 November 2024. Concerns included inadequate falls-risk assessment and reporting, insufficient documentation and monitoring, poor observability in a side room, and understaffing despite escalation.
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 undertake and evidence appropriate falls risk assessments
Wider context from the report “(1) There was a lack of evidence suggested appropriate falls risk assessments had been undertaken and a failure to report falls / collapses on the ward .
” Source location Sarah Kathleen Hill · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to report falls or collapses on the ward
Wider context from the report “(1) There was a lack of evidence suggested appropriate falls risk assessments had been undertaken and a failure to report falls / collapses on the ward .
” Source location Sarah Kathleen Hill · Prevention of Future Deaths report
Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete an urgent assurance check of falls documentation and current AMU patient monitoring.
Verbatim wording from the response “Immediate Assurance Check: An urgent assurance check on falls documentation and current patient monitoring on AMU is being completed to confirm improved compliance post-incident. Additionally, the ward has an established programme of work to undertake thematic reviews of falls related incidents (including collapses) on a quarterly basis to determine quality improvement plans and identify any new themes that ought to be shared with other teams or added to our Falls Trust Wide Improvement Plan.” Source location Response from North Cumbria Integrated Care NHS Foundation 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 Review ward falls assurance evidence against the Trust-wide Falls Improvement Plan and ward SMART plans.
Verbatim wording from the response “Compliance Review: The trust is reviewing the falls assurance evidence being captured by those wards undertaking Quality Accreditation to ensure that results are aligned with the Trust-wide Falls Improvement Plan and are linked to individual ward SMART improvement plans.” Source location Response from North Cumbria Integrated Care NHS Foundation 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 Revise the FRAMP policy to mandate reassessment after sedation, deterioration or procedures and reinforce prompt documentation.
Verbatim wording from the response “Protocol Update: The FRAMP policy will be revised to mandate reassessment following sedation, clinical deterioration, or medical procedures. This will include reinforcement of prompt documentation.” Source location Response from North Cumbria Integrated Care NHS Foundation 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 Deliver refresher incident-reporting training to AMU nursing staff covering falls, collapses, unwitnessed incidents and reporting thresholds.
Verbatim wording from the response “Incident Reporting Training: Refresher training is being delivered to all AMU nursing staff to clarify expectations around reporting collapses, falls, and unwitnessed incidents with an emphasis on always reporting even if there is doubt. Clarity will be included on borderline definitions and thresholds for reporting. This training will be expanded based upon the findings of the compliance review audit.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation FRAMP falls assessments were completed and updated appropriately; the identified failure concerned documenting and applying mitigating controls.
Verbatim wording from the response “Concern 1: Inadequate Falls Risk Assessment and Incident Reporting
Response:
The Trust acknowledges the failure to evidence appropriate falls risk assessment and timely incident reporting in Mrs Hill’s care.” Source location Response from North Cumbria Integrated Care NHS Foundation Trust
Open published response
28 Mar 2025 Derrick Frederick Tully · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1
Failure to record significant post-fall injuries in care notes View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Derrick Frederick Tully · 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
Derrick Frederick Tully was found deceased at home on 20 March 2024 after suffering a massive traumatic subdural haemorrhage, following months of falls and declining health. Concerns included unsuitable temporary accommodation, the absence of a key safe despite repeated concerns, an inappropriate reablement care package, failures to record or escalate injuries after a fall, and the discharge of Derrick from a community team without adequately factoring in his cognitive, mental health and safety difficulties.
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 record significant post-fall injuries in care notes
Wider context from the report “On 20 February Derrick suffered a fall. Severe bruising and swelling developed on his face over the following days but this was not recorded in his care notes by his carers and not escalated until his daughter raised concerns on 24 February. “No concerns” was written in Derrick’s care record and no consideration given to whether he needed to be reviewed by a doctor.
” Source location Derrick Frederick Tully · 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 mandatory refresher training on falls, head-injury recognition, recording, and escalation protocols to all care staff.
Verbatim wording from the response “5. Actions Taken and Proposed Further Action
Daryel Care is committed to learning from this incident and has taken and proposes the following actions to mitigate the risk of future similar occurrences:” Source location Response from Daryel Care
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 Enhance digital photographic injury-upload capability, obtaining explicit client consent in accordance with policy, to supplement written care-note descriptions.
Verbatim wording from the response “5. Actions Taken and Proposed Further Action
Daryel Care is committed to learning from this incident and has taken and proposes the following actions to mitigate the risk of future similar occurrences:” Source location Response from Daryel Care
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 Update care-documentation guidance and training with structured prompts for detailed injury descriptions and recording the rationale for non-escalation after initial reporting.
Verbatim wording from the response “5. Actions Taken and Proposed Further Action
Daryel Care is committed to learning from this incident and has taken and proposes the following actions to mitigate the risk of future similar occurrences:” Source location Response from Daryel Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The fall and developing injury were recorded in care notes, and the head injury was escalated promptly to the multi-disciplinary team.
Verbatim wording from the response “a. Recording of the Fall Incident (20 February 2024)
The assertion that the fall incident was "not recorded" is factually incorrect based on Daryel Care's existing records. The electronic care note entry for the visit commencing at 19:00 hrs on 20 February 2024, logged at 19:04 hours, explicitly documents the following: “The carer observed Mr Tully upon arrival with a fresh plaster wrap and wound dressing on his scalp. Mr Tully informed the carer he had sustained an injury from a fall. The carer” Source location Response from Daryel Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation No inappropriate “No concerns” entry attributable to staff was found in the official electronic care records, so its origin and context cannot be confirmed.
Verbatim wording from the response “d. Reference to "No Concerns" Entry
The PFD report states, ““No concerns” was written in Derrick’s care record". Daryel Care utilises the CM2000 electronic care monitoring and recording system for all care work visit notes. A review of all CM2000 electronic care notes logged by Daryel Care staff for Mr Tully between 20 February 2024 and the final visit on 22 February 2024 has been conducted. This comprehensive review has not located any entry made by a Daryel Care staff member within the CM2000 system during this period that contains the phrase "No concerns" or substantively similar wording used in an inappropriate context (i.e., as an overall assessment negating the known head injury). All located notes contain specific details pertinent to the care provided and observations made, including the entries regarding the head injury referenced above.” Source location Response from Daryel Care
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Daryel Care reported the fall to Adult Social Care, while ambulance attendance and hospital treatment had already addressed the immediate response.
Verbatim wording from the response “It is ASC’s understanding that Daryel Care was not requested to provide evidence to the coroner's court of their recording and reporting of the fall on the 20 February 2024. As part of ASC’s response to the PFD Notice, we have engaged Daryel Care who have provided their records. These evidence that on the 20 February 2024 at 19:12 ‘Derek sustained an injury on his face. He said he had an accident when he went out. The injury was plastered. I prompted his medication from the medication box, and he asked me to leave’.” Source location Response from Islington Council
Open published response
18 Mar 2025 Renate MARK · Prevention of Future Deaths report Northumberland
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Concerns raised 1
Misunderstanding of peripheral vision and witnessed or unwitnessed falls View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Renate MARK · 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
Renate MARK suffered an unwitnessed inpatient fall in hospital on 24 April 2024, sustaining a cervical spinal fracture and subdural haematoma, and died there on 25 April 2024 after receiving palliative care. Concerns included that she was assessed as a level 3 falls risk but was not under direct observation, that investigations relied on the incorrect belief that the fall was witnessed, and that too many patients at risk of falls were being monitored through peripheral vision. Further concern was raised about insufficient scrutiny of witness accounts during the Trust’s investigation.
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 Misunderstanding of peripheral vision and witnessed or unwitnessed falls
Wider context from the report “(2) The inquest heard that it is practice within the Trust that a Nursing Assistant is to be located centrally in the corridor on ward 9 to oversee patients assessed as at risk of falling and for the patients to be within staff's peripheral vision. The inquest heard that on 24 April 2024 8 patients were assessed as level 3 falls risk and 1 patient was assessed as level 4 falls risk. I am concerned as to the number of patients at risk of falls being observed in this way. I am further concerned that there is a misunderstanding of what is meant by peripheral vision and what constitutes a witnessed or unwitnessed fall .
” Source location Renate MARK · 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 Brief Ward 9 clinical staff on accurate witnessed and unwitnessed fall terminology and its use in incident reporting and communications.
Verbatim wording from the response “The incident concerning Mrs Mark occurred on Ward 9 of the Northumbria Specialist Emergency Care Hospital (NSECH). As an immediate response, the Trust is in the process of briefing the ward team, which includes all clinical staff, on what constitutes a 'witnessed' and 'unwitnessed' fall and the importance of ensuring that this terminology is understood and used accurately, where an incident occurs. The briefing will explain the importance of using accurate terminology is understood and used when information is disclosed to family following a falls incident, in order to allow for a robust internal Trust investigation and in circumstances” Source location Response from Northumbria NHS
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Revise the Integrated Falls Prevention Policy to define witnessed and unwitnessed falls, remove peripheral vision terminology, and replace it with line-of-sight wording.
Verbatim wording from the response “In terms of a Trust wide response, the Trust's Strategic Falls Group provides on the strategic direction and actions that are to be taken by the Trust where there is a patient safety incident concerning a falls risk. As a direct response to the concerns raised by HM Coroner in the PFD Report, the group has been tasked with undertaking a review of the Trust's current Integrated Falls Prevention Policy and to provide further detail within this policy, including the inclusion of a glossary, citing definitions of wording contained in the policy, which is to include the definition of a 'witnessed' and 'unwitnessed' fall. The use of the term 'peripheral vision' will be removed from the policy and replaced by the wording 'in line of sight' so as to avoid any potential confusion by staff.” Source location Response from Northumbria NHS
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 Disseminate the revised falls policy through governance approval, staff training, communications bulletins, meetings, safety huddles, and mandatory refresher training.
Verbatim wording from the response “The finalised policy will be agreed at governance level through the Trust's governance structure and thereafter will be included in the syllabus for future falls training sessions and events that are attended by all staff Trust wide, that are responsible for handling patients. The revised Integrated Falls Prevention Policy will then be supported by a Trust wide communication strategy to ensure staff are aware of the revised policy, and the policy updates contained therein. The Policy updates will be shared Trust wide via the Trust Communications Bulletin, Heads of Department meetings, site meetings via team meetings and ward safety huddles, led by the ward matron and also at governance meetings. In addition, the revised policy will continually be referred to in mandatory annual refresher falls training that is undertaken by all staff involved with handling patients.” Source location Response from Northumbria NHS
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.