Concerns raised 1
Failure to supervise residents at high risk of falls in the lounge area View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
×
AI-generated summary
Patricia Mary BARNETT · 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 Mary BARNETT died on 13 March 2026 from a head injury sustained in an unwitnessed fall at a care home on 26 February 2026. The principal concern was that she, a resident with reduced mobility, cognitive impairment and a high risk of falls, had been left unsupervised in the lounge area, creating a risk of future deaths.
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 supervise residents at high risk of falls in the lounge area
Wider context from the report “I am concerned that Mrs Barnett was left unsupervised in the lounge area . I am concerned that there is risk that future deaths could occur if residents who are suffering from reduced mobility and cognitive impairment and who are at high risk of falls are left unsupervised in the lounge area of the care home .
” Source location Patricia Mary BARNETT · Prevention of Future Deaths report
Open source report
13 Sep 2024 Paul Rodney Batchelor · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1
Lack of procedures for staff frightened or concerned about entering a resident’s room alone View source
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 3
The Red House
Require staff who feel unsure entering a resident’s room to seek help and enter with a colleague or duty nurse.
View source
The Red House
Deliver challenging-behaviour training covering triggers, de-escalation, safety, positive behavioural support, recording and post-incident procedures.
View source
The Red House
Deliver reflective-practice, lessons-learned and supervision sessions addressing response to resident calls and measures to prevent recurrence.
View source
×
AI-generated summary
Paul Rodney Batchelor · 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
Paul Rodney Batchelor, a frail elderly man in a care home for respite care, became wedged after a mattress extension fell through the frame of his extended nursing bed and died of positional asphyxia and bronchopneumonia. His cries for help went unattended for over an hour. The concerns were inadequate support for mattress extensions on extended beds and the lack of formalised procedures for staff responding to distressed residents at night, including when staff are frightened or concerned about entering a room alone.
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 procedures for staff frightened or concerned about entering a resident’s room alone
Wider context from the report “Second Concern: The coroner notes that the care home has taken steps to ensure that any resident in distress and calling for help at night is heard. However, though the coroner has been shown minutes of briefings to care home staff conducted after Mr Batchelor’s death emphasising the need to conduct checks of residents by going into a resident’s room, she remains concerned that such briefings have not been formalised into care home policy and procedures. Nor do the minutes of those briefings explain what staff should do if they are frightened or concerned about entering a room on their own . There is the risk that rather than disturb a resident care home staff through, for example, fear or lack of time do not check a resident who may be in distress.
” Source location Paul Rodney Batchelor · 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 Require staff who feel unsure entering a resident’s room to seek help and enter with a colleague or duty nurse.
Verbatim wording from the response “Post incident action
The Red House has taken several steps immediately following the incident.
The Manager met with care staff the following day and conducted reflective practice/lessons learnt with the staff present during the incident.
The Manager then met with all staff, who were made aware of the risks of not responding to a call for assistance from a resident and the tragic consequences that can occur. All staff received individual supervision sessions and group supervision where this incident was discussed, and measures put in place to prevent a recurrence.
Staff were instructed that if they felt unsure for any reason responding to a resident call for assistance, then they are to inform a colleague and enter in pairs, or the duty nurse. The individual supervision with DS (carer) clearly outlines what action to be taken if she felt unsure about entering a resident’s room.” Source location Response from The Red House
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 challenging-behaviour training covering triggers, de-escalation, safety, positive behavioural support, recording and post-incident procedures.
Verbatim wording from the response “Individual supervision with DS (Carer) | 29/06/2023 | ATTACHED 29/10/2024
Lessons learnt session with DS (Carer) | 29/06/2023 | 26/01/2024
Lessons learnt session with SM (RGN) | 29/06/2023 | 26/01/2024
Lessons learnt session with DP (Carer) | 29/06/2023 | 26/01/2024
Night allocation – reviewed | 05/07/2023 | In oral evidence
--monthly Bed Condition Reports instigated | Dec 2023 | In oral evidence
Challenging Behaviour Support training | 30/04/2024 | ATTACHED 29/10/2024
Staff meeting – Flash | 03/07/2024 | 30/08/2024
General staff meeting | 09/08/2024 | 30/08/2024
General staff meeting | 14/08/2024 | ATTACHED 29/10/2024
Group supervision / lessons learnt | 17/09/2024 | ATTACHED 29/10/2024
Individual staff supervision – all staff | 18/09/2024 | ATTACHED 29/10/2024
Permanent staff Induction amended | 19/09/2024 | ATTACHED 29/10/2024
Agency staff Induction amended | 19/09/2024 | ATTACHED” Source location Response from The Red House
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 reflective-practice, lessons-learned and supervision sessions addressing response to resident calls and measures to prevent recurrence.
Verbatim wording from the response “Action Taken | Date of Action | Date Evidence Sent to Coroner
Review of staffing levels | 26/06/2023 | ATTACHED 29/10/2024
Urgent Flash Reflective Debrief meeting | 29/06/2023 | 26/01/2024
Staff meeting – flash | 29/06/2023 | 30/08/2024” Source location Response from The Red House
Open published response
16 Apr 2024 Edith Jane ALDEN · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to prevent falls through timely intervention when very high-risk residents mobilise View source
This report raised 6 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
Norfolk Care Homes
Introduce a Falls Champion role and competency checks to provide ongoing falls-prevention coaching and verify staff knowledge.
View source
Norfolk Care Homes
Review and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.
View source
Norfolk Care Homes
Review and introduce assistive technology in communal and bedroom areas to alert staff when residents attempt to mobilise independently.
View source
Norfolk Care Homes
Allocate care staff to communal areas and provide staffed garden access with radios for rapid communication.
View source See 1 more action
×
AI-generated summary
Edith Jane ALDEN · 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
Edith Jane Alden, a resident assessed at very high risk of falls, left a communal area unnoticed and unsupervised on 13 September 2021, fell in the garden and suffered severe head injuries. She died on 25 September 2021. Concerns included unclear and inconsistent care plans and risk assessments, insufficient supervision and staffing, and the use of unlocked communal-area access for residents at very high risk of falls.
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 prevent falls through timely intervention when very high-risk residents mobilise
Wider context from the report “6. Residents deemed as at very high risk of falls were, and still are, in their bedrooms with a call bell and no other means to alert staff if they get out of bed and mobilise, this includes leaving their room and entering corridor areas. I am concerned this will lead to carers responding to a fallen resident, rather than preventing the fall.
” Source location Edith Jane ALDEN · 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 Introduce a Falls Champion role and competency checks to provide ongoing falls-prevention coaching and verify staff knowledge.
Verbatim wording from the response “Training
We have reviewed the training we have in place to support staff. We have introduced a ‘Falls Champion’ role to provide continuous drive and improvements to our working practices. This is an active member of the staff team providing support, guidance and coaching around falls prevention. Knowledge and understanding checks through competency assessment and sign off following completion of this for each staff member. Our in house trainer has completed a falls, train the trainer programme, date 21st May 2024 this will also support ongoing improvements for both the training package being provided and the Falls Champion role. We will continue to develop and adapt our training with further awareness sessions being offered to friends, families and advocates etc.” Source location 2024-0196 Response from The Limes Care Home
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 and update falls-related policies, procedures and auditing processes to identify inconsistencies and improve staff guidance.
Verbatim wording from the response “Policies and procedure reviews
Policies and procedures are continuously reviewed as part of our development as a company. Special emphasis has been given to any of our policies linked to falls, including environmental factors, individual risks, actions to be taken to improve staff guidance around understanding and interventions required to mitigate risks where possible.” Source location 2024-0196 Response from The Limes Care Home
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 and introduce assistive technology in communal and bedroom areas to alert staff when residents attempt to mobilise independently.
Verbatim wording from the response “Assistive technology review of all equipment currently in use, additional equipment considered and introduced where appropriate. Equipment is reviewed following any changes to an individual’s physical, mental or emotional health. This is evidenced within assessments linked to the relevant change and within weekly clinical meetings. Management, senior staff are responsible for making these changes.” Source location 2024-0196 Response from The Limes Care Home
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 Allocate care staff to communal areas and provide staffed garden access with radios for rapid communication.
Verbatim wording from the response “Care staff are allocated to communal areas of the home to provide relevant help and support for any residents within these areas.” Source location 2024-0196 Response from The Limes Care Home
Open published response
19 Dec 2023 MORGAN-ROSE HART · Prevention of Future Deaths report Essex
View report summary
Concerns raised 1
Failure to ensure in-person checks after bathroom alerts View source
This report raised 10 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response
Essex Partnership University 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
Essex Partnership University NHS Foundation Trust
Configure Oxevision bathroom alerts to repeat audibly and visually at three-minute intervals until the bathroom is exited.
View source
Essex Partnership University NHS Foundation Trust
Review and update Oxevision and observation procedures to align terminology and clarify alert-reset functionality.
View source
Essex Partnership University NHS Foundation Trust
Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
View source
Essex Partnership University NHS Foundation Trust
Monitor Oxevision use through ward spot checks, DATIX review and maintained training records.
View source See 1 more action
×
AI-generated summary
MORGAN-ROSE HART · 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
Morgan-Rose Hart, who was detained on a female mental health ward, died on 12 July 2022 after being found unresponsive with a ligature around her neck. The report identified concerns about missed and falsified observations, failures to complete physical welfare checks after bathroom alerts, inadequate escalation of risk, shortcomings in investigation and record keeping, and insufficient suitable placements for people with autism and mental health and self-harm risks in Essex.
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 ensure in-person checks after bathroom alerts
Wider context from the report “(4) Bathroom alerts – Evidence was heard that an Oxevision alert is triggered if a person is in the bathroom for more than 3 minutes and staff are required to complete an in-person check . Morgan-Rose was left in the bathroom unobserved for approximately 50 minutes . It was not clear from the evidence how the Trust proposes to ensure compliance in respect of this duty .
” Source location MORGAN-ROSE HART · 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 Configure Oxevision bathroom alerts to repeat audibly and visually at three-minute intervals until the bathroom is exited.
Verbatim wording from the response “Configuration changes to the Oxevission system have been implemented. This will ensure that bathroom alerts continue at 3 minute intervals until an individual has exited the bathroom. This includes the reset functionality of a repeatable and audible and tile illumination of an alert with timer continuation after each successive reset of the alert in 3-minute intervals.” Source location Response from Essex Partnership University NHS Foundation Trust
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 and update Oxevision and observation procedures to align terminology and clarify alert-reset functionality.
Verbatim wording from the response “A clinical review of the SOPs for Oxevission and Oxevission Observations to align terminology and produce updated versions of the SOPs has been implemented. This includes ensuring the continuity of terminology in the SOP and all communications mirroring system based terms and wording.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Train and retrain clinical staff in Oxevision, electronic observations and supportive-observation requirements.
Verbatim wording from the response “All clinical staff are being retrained or trained in the use of Oxevission and observations. In line with the Oxevission SOP and the Therapeutic engagement and supportive observation policy.” Source location Response from Essex Partnership University NHS Foundation Trust
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 Monitor Oxevision use through ward spot checks, DATIX review and maintained training records.
Verbatim wording from the response “DATIX data reflects that staff are using Oxevission in adherence to policy and responding to alerts which has resulted in no harm. The Inpatient Leadership team continue to spot check ward practice and review DATIX data.” Source location Response from Essex Partnership University NHS Foundation Trust
Open published response
Concerns raised 1
Failure to provide appropriate supervision for a resident with evolving dementia View source
This report raised 8 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.
×
AI-generated summary
Julia MURPHY · 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
Julia Murphy, known as Sheila, died in hospital on 9 April 2023 after a fall in her care home caused a hip fracture and her condition deteriorated. The report raises concerns about repeated falls, incomplete or inaccurate referrals to the falls prevention team, inadequate escalation, and failure to formally seek one-to-one supervision funding where appropriate.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to provide appropriate supervision for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” Source location Julia MURPHY · Prevention of Future Deaths report
Open source report
Concerns raised 2
Failure to monitor residents when carers attend competing care needs View source Insufficient staffing capacity to meet competing resident care and monitoring needs View source
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 6
PINE VIEW CARE HOMES LTD
Update and implement policies covering staffing hours, slips, trips and falls, observations, and general risk assessments.
View source
PINE VIEW CARE HOMES LTD
Employ a third daytime staff member to maintain lounge supervision and assist residents across the home.
View source
PINE VIEW CARE HOMES LTD
Apply graduated resident-observation procedures, including overnight monitoring and immediate response to sensor alerts.
View source
PINE VIEW CARE HOMES LTD
Install and use bedroom sensor mats and CCTV cameras to detect and monitor residents’ movement.
View source
PINE VIEW CARE HOMES LTD
Conduct regular staff training on the risks of leaving residents unmonitored or unattended.
View source
PINE VIEW CARE HOMES LTD
Continuously assess residents’ dependency and care needs to determine required staffing hours and mitigate risks.
View source See 3 more actions
×
AI-generated summary
Janet SMITH · 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
Janet Smith, an 81-year-old woman with advanced dementia and ischaemic heart disease, sustained spinal fractures after an unwitnessed fall at her care home on 15 March 2022 and died on 22 March 2022 after deterioration and placement on palliative care. The principal concern was that insufficient staffing meant no carer was monitoring the lounge, allowing her to leave unattended, and that the provider had not done everything possible to mitigate the risk of harm or death from residents being left unmonitored.
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 monitor residents when carers attend competing care needs
Wider context from the report “At the time of Mrs. Smith's fall, there were 17 residents and 2 carers. One carer was attending a resident upstairs and the other carer was outside the care home accompanying another resident who wished to have a cigarette. This meant that no carer was in the lounge area monitoring the residents. Accordingly, when Mrs. Smith left the lounge area she was not monitored as required . If she had been monitored, it is understood that she would have been offered assistance and, on a balance of probabilities, the fall that led to her death would not have occurred.
It was understood that at the care home there were, and still is, a number of residents with challenging behaviour and care needs, and that for some activities of daily living 2 carers may be required. With only 2 carers on a shift, it is foreseeable that residents can and will be left unattended. It is also foreseeable that competing needs of the residents will mean that residents will be left unmonitored, and an unsafe environment created as occurred with Mrs. Smith. Accordingly, there remains a concern that the provider has not done everything possible to mitigate the risk of actual or potential harm including death.
” Source location Janet SMITH · Prevention of Future Deaths report
Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient staffing capacity to meet competing resident care and monitoring needs
Wider context from the report “At the time of Mrs. Smith's fall, there were 17 residents and 2 carers. One carer was attending a resident upstairs and the other carer was outside the care home accompanying another resident who wished to have a cigarette. This meant that no carer was in the lounge area monitoring the residents. Accordingly, when Mrs. Smith left the lounge area she was not monitored as required. If she had been monitored, it is understood that she would have been offered assistance and, on a balance of probabilities, the fall that led to her death would not have occurred.
It was understood that at the care home there were, and still is, a number of residents with challenging behaviour and care needs, and that for some activities of daily living 2 carers may be required. With only 2 carers on a shift, it is foreseeable that residents can and will be left unattended. It is also foreseeable that competing needs of the residents will mean that residents will be left unmonitored, and an unsafe environment created as occurred with Mrs. Smith. Accordingly, there remains a concern that the provider has not done everything possible to mitigate the risk of actual or potential harm including death.
” Source location Janet SMITH · 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 Update and implement policies covering staffing hours, slips, trips and falls, observations, and general risk assessments.
Verbatim wording from the response “We have reviewed our policies and procedures and, for the benefit of the Coroner, we attach the following updated polices and a staffing hours analysis:” Source location Response from Pine View Care Homes 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 Employ a third daytime staff member to maintain lounge supervision and assist residents across the home.
Verbatim wording from the response “We now employ a third member of staff during the day from 9a.m. to 7.00p.m. Sometimes 2 staff members are required to assist residents located in different areas of the care home and to bring residents to different parts of the home for various reasons. A third member of staff remains in the lounge area at all times to monitor and assist residents. Therefore, a member of staff will be present in the lounge room to care for and monitor residents and ensure that residents are not left unattended. This will hopefully assist in trying to mitigate the risk of residents falling in the future as someone will always be present to monitor, assist and tend to residents at all times.” Source location Response from Pine View Care Homes 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 Apply graduated resident-observation procedures, including overnight monitoring and immediate response to sensor alerts.
Verbatim wording from the response “At times, a resident’s mood and behaviour pattern fluctuates and they may be required to be observed at increased levels to ensure their own safety, the safety of other residents and the safety of staff. Staff and management conduct a risk assessment for residents which is then regularly reviewed by management and staff to ensure the appropriate level of observation is in place for the resident’s needs at any particular time.” Source location Response from Pine View Care Homes 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 Install and use bedroom sensor mats and CCTV cameras to detect and monitor residents’ movement.
Verbatim wording from the response “We have also installed sensor mats in bedrooms, for those residents deemed at high risk of falls, with their consent or through a DOLS application allowing the care home to deprive residents due to having no capacity, and CCTV cameras throughout the home to enable management to monitor and observe the movement of residents.” Source location Response from Pine View Care Homes 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 Conduct regular staff training on the risks of leaving residents unmonitored or unattended.
Verbatim wording from the response “In addition to the above, we will conduct regular training sessions for all staff to ensure that all members of staff are educated about the potential risks and harm from leaving residents unmonitored / unattended and their knowledge is kept up to date.” Source location Response from Pine View Care Homes 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 Continuously assess residents’ dependency and care needs to determine required staffing hours and mitigate risks.
Verbatim wording from the response “Each of our residents require different levels of support and care. Accordingly, their dependency levels (i.e. the amount of time staff should spend with each client) can differ at different times. We continuously review and monitor our residents’ support and care needs and these needs are then graded using our dependency level formula to establish the number of hours staff are required to spend with each resident.” Source location Response from Pine View Care Homes LTD
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing staffing, monitoring, policies, training and environmental controls are considered sufficient to keep residents safe and mitigate falling risks.
Verbatim wording from the response “These above policies will hopefully ensure that residents are not left unattended or unmonitored and the risks of residents slipping, tripping and falling is minimised in the future. We believe that residents are safe, they live in a safe environment and they are supported by dedicated staff who are appropriately trained and are capable of assisting residents in the event of a fall.” Source location Response from Pine View Care Homes LTD
Open published response
15 Mar 2023 Tarik Roger Drakes · Prevention of Future Deaths report Dorset
View report summary
Concerns raised 2
Insufficient staffing and supervision of residents outside staffed hours and at weekends View source Failure to monitor and safeguard access to, and presence within, the accommodation View source
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Tarik Roger Drakes · 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
Tarik Roger Drakes, who had a history of using heroin, was found collapsed and unresponsive at his supported accommodation on 12 November 2022. He was taken to hospital, where he was found to be in multi-organ failure, and died on 29 November 2022. Concerns were raised about staffing, welfare checks, monitoring, supervision, safeguarding, emergency access, and follow-up of his support needs at the accommodation.
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 Insufficient staffing and supervision of residents outside staffed hours and at weekends
Wider context from the report “1. During the inquest evidence was heard that:
i. Dorset Lodge is a supported housing accommodation facility with 16 rooms that provides accommodation for those who have drug and alcohol addictions. It is owned and managed by Bournemouth Churches Housing Association (BCHA) and they are contracted to provide the housing to residents by BCP Council. It is staffed Monday to Friday, between 8am to 8pm by two support workers, one covering a shift from 8am to 4pm and the other covering a shift from 12noon to 8pm. When the support staff are unavailable, agency staff will cover the support worker role. On Saturdays a support worker is present, but this is not on a contracted basis and if she is on leave there is no cover. Outside the hours of 8am to 8pm, and on weekends, when there is no support worker on site, there is a night response team who will not be on site but attend twice during the night period to conduct perimeter checks of the building. The premises is covered by CCTV, inside and outside, which can be monitored remotely.
ii. To provide support to the residents, the support workers will undertake key worker sessions which are offered weekly. When agency staff cover the shifts, when the usual support workers are covering other sites or on leave, they do not undertake key worker sessions.
iii. Entry to the premises is gained using a key fob system. Entry is monitored by staff when on site, but between 8pm and 8am, and at weekends when no staff members are on site, residents are able to let people in without any monitoring or safeguarding measures in please.
iv. Evidence was given that those at Dorset Lodge are vulnerable due to their addictions. Mr Drakes’ family gave evidence that he had disclosed to them that residents were using drugs within the premises, and they described the times when staff were not present as “party time” with non-residents entering the premises. Even when staff are on duty there is no monitoring of who is in the premises, such as by a signing in and out book. Staff undertake welfare checks upon residents 3 times a day at 10.30am, 3.30pm and 7.30pm, however evidence was given that it is not clear who is present at any one time.
v. When the police attended Room 14 at Dorset Lodge on the Thursday 17th November, items of drug paraphernalia were found in the room including needles, a sharps box and a homemade pipe. The room had been insecure from 12th November when Mr Drakes was taken to hospital and there was evidence people had been in the room after that time as items had been removed from the room and residents called the Police to report concerns.
vi. Evidence was given by the family that when they attended the premises on the 14th November they tried to call the number on the front door, which was out of hours number, and it was a dead line. Unless a resident allows someone entry, this would be the only route of access to Dorset Lodge by emergency services, such as the paramedics, out of staffed hours to provide care in an emergency, which could delay entry and access to treatment.
vii. Mr Drakes was last seen alive on CCTV at Dorset Lodge at 0.44 hours on the 12th November. Paramedics were called at 16.07 hours that day by other residents. As this was a Saturday, and the support worker who did work some Saturdays was not working that day, there were no welfare checks undertaken upon him by staff. It is not possible to say what would have happened if he had been checked by staff or taken to hospital sooner.
viii. Mr Drakes was deemed to be vulnerable by the manager at Dorset Lodge and there were professional meetings held to discuss, amongst other things, his placement and need for 24 hour support. The last of these professional meetings was held on the 10th August 2022. One was scheduled for the 9th September 2022 but no one was available and the meeting was not rescheduled prior to the 12th November. There was no follow up meeting about his needs after the meeting on the 9th September did not go ahead.
2. I have concerns with regard to the following:
i. That there could be the death of a resident at Dorset Lodge under the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge and I would request that consideration is given to reviewing the current levels of staffing and supervision at the placement , and the processes and procedures in place around support to the residents.
” Source location Tarik Roger Drakes · 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 monitor and safeguard access to, and presence within, the accommodation
Wider context from the report “1. During the inquest evidence was heard that:
i. Dorset Lodge is a supported housing accommodation facility with 16 rooms that provides accommodation for those who have drug and alcohol addictions. It is owned and managed by Bournemouth Churches Housing Association (BCHA) and they are contracted to provide the housing to residents by BCP Council. It is staffed Monday to Friday, between 8am to 8pm by two support workers, one covering a shift from 8am to 4pm and the other covering a shift from 12noon to 8pm. When the support staff are unavailable, agency staff will cover the support worker role. On Saturdays a support worker is present, but this is not on a contracted basis and if she is on leave there is no cover. Outside the hours of 8am to 8pm, and on weekends, when there is no support worker on site, there is a night response team who will not be on site but attend twice during the night period to conduct perimeter checks of the building. The premises is covered by CCTV, inside and outside, which can be monitored remotely.
ii. To provide support to the residents, the support workers will undertake key worker sessions which are offered weekly. When agency staff cover the shifts, when the usual support workers are covering other sites or on leave, they do not undertake key worker sessions.
iii. Entry to the premises is gained using a key fob system. Entry is monitored by staff when on site, but between 8pm and 8am, and at weekends when no staff members are on site, residents are able to let people in without any monitoring or safeguarding measures in please.
iv. Evidence was given that those at Dorset Lodge are vulnerable due to their addictions. Mr Drakes’ family gave evidence that he had disclosed to them that residents were using drugs within the premises, and they described the times when staff were not present as “party time” with non-residents entering the premises. Even when staff are on duty there is no monitoring of who is in the premises, such as by a signing in and out book. Staff undertake welfare checks upon residents 3 times a day at 10.30am, 3.30pm and 7.30pm, however evidence was given that it is not clear who is present at any one time.
v. When the police attended Room 14 at Dorset Lodge on the Thursday 17th November, items of drug paraphernalia were found in the room including needles, a sharps box and a homemade pipe. The room had been insecure from 12th November when Mr Drakes was taken to hospital and there was evidence people had been in the room after that time as items had been removed from the room and residents called the Police to report concerns.
vi. Evidence was given by the family that when they attended the premises on the 14th November they tried to call the number on the front door, which was out of hours number, and it was a dead line. Unless a resident allows someone entry, this would be the only route of access to Dorset Lodge by emergency services, such as the paramedics, out of staffed hours to provide care in an emergency, which could delay entry and access to treatment.
vii. Mr Drakes was last seen alive on CCTV at Dorset Lodge at 0.44 hours on the 12th November. Paramedics were called at 16.07 hours that day by other residents. As this was a Saturday, and the support worker who did work some Saturdays was not working that day, there were no welfare checks undertaken upon him by staff. It is not possible to say what would have happened if he had been checked by staff or taken to hospital sooner.
viii. Mr Drakes was deemed to be vulnerable by the manager at Dorset Lodge and there were professional meetings held to discuss, amongst other things, his placement and need for 24 hour support. The last of these professional meetings was held on the 10th August 2022. One was scheduled for the 9th September 2022 but no one was available and the meeting was not rescheduled prior to the 12th November. There was no follow up meeting about his needs after the meeting on the 9th September did not go ahead.
2. I have concerns with regard to the following:
i. That there could be the death of a resident at Dorset Lodge under the current processes in place regarding the monitoring, supervision and safeguarding of residents at Dorset Lodge and I would request that consideration is given to reviewing the current levels of staffing and supervision at the placement, and the processes and procedures in place around support to the residents.
” Source location Tarik Roger Drakes · 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 Maintain additional Night Response Team presence at Dorset Lodge during evening hours.
Verbatim wording from the response “NRT have been asked to be present as an additional measure at Dorset Lodge for a couple of hours per night where possible due to a recent increase in activity during March of visitors and some concerns of ASB (Anti-Social Behaviour) which are not related to the concerns highlighted in the inquest of Mr Drakes. This is to determine where this is happening and who is responsible so action can be taken where appropriate. As an organisation we do this as a matter of course when concerns are made known to us. This was identified through routine night checks.” Source location Response from BCHA
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 Night Response Team offer to enhance physical evening presence across sites.
Verbatim wording from the response “The NRT service undertake a perimeter check where possible nightly across the properties that are covered. This consists of a walk around the building, checking any safety issues, ensuring doors are closed and secured, emergency lighting is working, barriers are working, no damage and no intruders in the vicinity. At some services, the NRT have also supported customers who have been locked out of the building to gain entrance when available. This is supported at Dorset Lodge on occasion. CCTV is not ‘monitored’ through the night but there is currently remote access which can be viewed/accessed if required. We are currently undertaking a review of our NRT offer which we hope will allow for greater physical presence across sites through the evening.” Source location Response from BCHA
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Weekend staffing was not commissioned; residents were assessed as suitable for available support, with 24/7 accommodation available for greater needs.
Verbatim wording from the response “Dorset Lodge is not commissioned to provide support or keyworking over the weekend. The Saturday role is an ‘added value’ role. The role is an activity coordination role to give customers something to do over the weekend. E.g. the role may undertake cooking activities or arts and crafts. This role is not funded and is used ad hoc throughout the year. Customers who are referred and assessed to live at Dorset Lodge are deemed through link meetings as suitable for the level of support available. Alternative 24/7 staffed accommodation is available for those with greater needs at St Pauls in Bournemouth. Customers also have a right to choose where they live and determine what support they would like to engage with.” Source location Response from BCHA
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A move to 24/7 accommodation was not pursued because it was considered unsuitable and the resident preferred to remain at Dorset Lodge.
Verbatim wording from the response “Moving Mr Drakes to a 24/7 staffed site had been considered and there were reasons why this was not deemed suitable for Mr Drakes and his multi-agency support. Mr Drakes’ housing status was a regular feature of discussions and review both with partners and with Mr Drakes. Mr Drakes also expressed his preference to remain at Dorset Lodge.” Source location Response from BCHA
Open published response
×
Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation A signing-in book was not required for this HMO, and the accommodation was fully fire compliant under applicable legislation.
Verbatim wording from the response “Dorset Lodge is not a secure living facility and there is no requirement on site for customers to complete a signing in book, guests are always the responsibility of tenants. As an HMO there is no requirement for a signing in book for fire safety reasons. Dorset Lodge is fully fire compliant as per legislation.” Source location Response from BCHA
Open published response
Concerns raised 1
Failure to continuously monitor residents View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
×
AI-generated summary
Lugh Baker · 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
Lugh Baker, a 24-year-old man with Angelman’s syndrome, epilepsy and difficulty swallowing, was found unresponsive at Rosewood House on 21 April 2021 after receiving medication in a chocolate milkshake. CPR was unsuccessful, and the cause of death was recorded as unascertained with an Open Conclusion. Concerns included gaps in monitoring, delays in reviewing new residents’ care plans, and insufficient arrangements for staff unfamiliar with a resident’s unusual presentation.
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 continuously monitor residents
Wider context from the report “i) I heard evidence at inquest that all residents were constantly monitored yet I found as fact that there were times when this did not happen for Lugh . I was informed that a new system has been put in place requiring staff to sign a form indicating the periods in time when they were responsible for monitoring residents. I asked for evidence to demonstrate this (a completed form) and for confirmation that, where there were any gaps in monitoring, these were explained on the form.
” Source location Lugh Baker · 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 Update the nocturnal CCTV monitoring chart to record monitoring periods and explain any gaps.
Verbatim wording from the response “2. Updated Nocturnal CCTV Monitoring Chart” Source location Response from Bowden Derra Park ltd
Open published response
27 Feb 2023 Peter Gary SEABY · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 1
Failure to formalise allocation of resident supervision and meal preparation duties 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. 2
Priory Group
Strengthen role allocation, mealtime responsibilities and staff handover processes following staff feedback and debriefing.
View source
Priory Group
Conduct mealtimes in two sittings to enable closer supervision while residents eat and drink.
View source
×
AI-generated summary
Peter Gary SEABY · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Peter Gary Seaby was a resident of The Oaks and Woodcroft Care Home who died in hospital on 22 May 2018 after choking-related symptoms and subsequent aspiration pneumonia. His lunchtime food was not prepared in accordance with his SALT Care Plan, and he did not receive the required one-to-one supervision; the inquest found these possibly contributed to his death. The report also identified concerns about informal care arrangements, staffing levels, and the absence of an internal review after his 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 formalise allocation of resident supervision and meal preparation duties
Wider context from the report “1. Evidence was heard at the inquest of the “informal approach” taken with regard to arrangements as to who would provide supervision of residents, including on a one to one basis and who would cook and prepare their meals, including those residents who were subject to a specific SALT dietary plan . Evidence was also heard of steps which have been put in place since Mr Seaby’s death to provide written staff rotas for such matters, prepared by Team Leaders and Deputy Managers. However, despite these steps being taken, evidence was also heard at the inquest from staff, who continue to provide care at Oaks and Woodcroft Care Home, referring to providing care on an “informal basis” and that this “works”.
” Source location Peter Gary SEABY · 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 Strengthen role allocation, mealtime responsibilities and staff handover processes following staff feedback and debriefing.
Verbatim wording from the response “Since the Inquest we have offered support to the staff member and explored with her what ████████ meant by the term ‘informal’. We have asked her to identify the areas of day-to-day practice that ████████ feels would benefit from being made more precise. More widely, the staff team as a whole have been given feedback, as part of the debrief process, on the outcome and learning from the Inquest and have been asked for their views on resident care and what, if any, improvements need to be made. This exercise has resulted in some additional improvements having been made in terms of the process for allocation of roles, staff understanding their roles and responsibilities particularly at mealtimes and the process for staff handovers having been strengthened.” Source location Response from Priory
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 Conduct mealtimes in two sittings to enable closer supervision while residents eat and drink.
Verbatim wording from the response “On a practical level, meal times are now undertaken in two sittings to enable closer supervision of each resident whilst eating and drinking.” Source location Response from Priory
Open published response
Concerns raised 1
Failure to effectively observe vulnerable residents entering the garden 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
WESTLANDS CARE HOME LTD
Install an additional beam to detect garden entry when doors are open.
View source
×
AI-generated summary
Hazel Lillian MAYHO · 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 Lillian MAYHO, aged 82, died on 27 May 2022 after suffering a brain injury when she fell in the garden of a nursing home. The report raised concerns about hazards in the garden, staff being unable to effectively observe vulnerable residents, and the absence of an effective exit control or alert system for residents at risk of entering the garden alone.
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 effectively observe vulnerable residents entering the garden
Wider context from the report “The deceased was 82 years of age, was severely frail and suffered from dementia. The deceased was assessed as being at high risk of falls and a reputation for wandering around the establishment. The deceased was not unique amongst the other residents in having such vulnerabilities.
The lounge areas of the nursing home have doors leading to the garden. The garden has within it potential hazards to a vulnerable resident with a high risk of falls. The doors are kept wide open in warm weather. Whether a resident has entered the garden is only known if they are observed by a member of staff to do so. Members of staff are frequently distracted by other duties hindering their ability to fully and effectively observe vulnerable residents entering the garden. There is an absence of an effective exit control process to ensure that those with a recognised risk of entering the garden alone are prevented from doing so or an effective alert system is triggered when they do so.
” Source location Hazel Lillian MAYHO · 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 Install an additional beam to detect garden entry when doors are open.
Verbatim wording from the response “An additional beam has been installed (8th December 2022) – this allows the doors to be open when required in hot weather at residents’ request but it now allows for staff to know if someone has entered into the garden without them being observed should they be busy and not able to see if this has happened as mentioned in your report, this is a separate beam to the door opening and closing.” Source location Response from Westlands Care Home
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.