Recurring concern

Failure to update risk assessments after material changes or safety events

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First reported 12 Feb 2015•Latest report 1 Jun 2026

Definition

What this concern includes

Includes failures to review or update a risk assessment after a material change, deviation from an agreed safety plan, significant deterioration, suspected overdose, intoxication, injury, incident or other safety event that should trigger reassessment, including failures to maintain a reliable process for timely updating.

Not included

Excludes deficiencies limited to completing an initial risk assessment where no failure to update after a material change or safety event is identified.
Excludes failures in a separately named risk-assessment system or hazard when that named system supplies the more specific supported recurring concern.
Excludes generic care planning, documentation, training or staffing deficiencies unless they directly result in failure to update a risk assessment after a material change or safety event.
Excludes failures to implement risk-reduction actions after an otherwise current risk assessment unless updating the assessment is also deficient.

Reports: 28
Individual concerns: 30
Date range: 2015–2026
Stated actions: 63

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Reports about this concern sent to each recipient.

Care Quality Commission3

Department of Health and Social Care3

Birmingham and Solihull Mental Health NHS Foundation Trust2

Essex Partnership University NHS Foundation Trust2

HM Prison and Probation Service2

NHS England2

Adullam Homes Housing Association Limited1

Arjo UK Limited1

Barchester Healthcare Limited1

Berrywood Hospital1

Care UK1

Castlehill Specialist Care Centre1

Cole Valley Care Limited1

Department of Community Mental Health, Woolwich Station Medical Centre1

Globe Court Care Home1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

1 Jun2026
Essex
Concerns raised1
1. Failure to maintain collaborative, complete and accurate risk assessments and care plans
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Katharine Emma Corrigan · 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

Katharine Emma Corrigan, a patient detained under the Mental Health Act, died by suicide after failing to return from unescorted leave on 22 July 2023. The report identifies concerns about failures in the management and recording of Section 17 leave, inadequate risk assessments and care planning, staffing and oversight, and failures concerning access to recognised treatment for a pre-existing hormonal imbalance.

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 maintain collaborative, complete and accurate risk assessments and care plans
Wider context from the report
“6. Ms Corrigan’s risk assessment and care plans had not been appropriately updated in her medical records such that: a. They had not been developed in collaboration with her and did not contain: i. Early warning signs and triggers ii. Which mitigations were appropriate iii. Rationale as to why section 17 leaves were granted and/or rescinded b. With accurate risk information of her presentation and deterioration on the ward and with concerns raised by Family which were put in writing to the responsible clinician c. They contained inaccurate information on fire safety that had never been a part of her presentation . It was not understood where this had emanated from. d. That Ms Corrigan had tried to get rid of all her clothes and this was behaviour Ms Corrigan had previously displayed before attempting to end her life. e. That her mental health deteriorated in the days prior to her death and staff were concerned about the risks to herself due to her low mood. Nursing staff instigated the risk protocol such that Ms Corrigan should not have been able to access section 17 leave until reviewed by the multidisciplinary team and there was confusion about the Level of observations that had been put in place for Ms Corrigan on 21 July. Medical records and section 17 leave forms were not amended to ensure that staff could understand that due to her low mood with consequent risks, leave must not take place until a medical review. ”
Source location
Katharine Emma Corrigan · Prevention of Future Deaths report
Page 4 · concerns
Open source report
14 Nov2025
Manchester South
Concerns raised1
1. Failure to complete and update falls risk assessments after falls
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Adopt a comprehensive pre-admission protocol to create complete care plans and risk assessments from admission.
  Stated by The Lakes Care CentreStated completed
2. Action
  Allocate monthly care-plan and risk-assessment reviews to Senior Carers and Leaders, with interim updates communicated to staff.
  Stated by The Lakes Care CentreStated completed
3. Action
  Implement falls protocols requiring every fall to be reported, digitally recorded and followed by reassessment when needs may have changed.
  Stated by The Lakes Care CentreStated completed
AI-generated summary

Ronald PERRY · 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

Ronald Perry became increasingly frail after discharge to The Lakes Care Home and experienced several falls, including a fall on 25 April 2025 that resulted in a brain bleed and fractures. He deteriorated after surgery and died at Salford Royal Hospital on 30 May 2025. Concerns included poor care and risk documentation, incomplete falls risk assessments, and inconsistent adherence to the policy on seeking medical advice for unwitnessed falls involving residents on anticoagulants.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to complete and update falls risk assessments after falls
Wider context from the report
“2. The falls risk assessment documentation was incomplete and did not appear to have been updated after falls had occurred. ”
Source location
Ronald PERRY · Prevention of Future Deaths report
Page 2 · concerns
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
Adopt a comprehensive pre-admission protocol to create complete care plans and risk assessments from admission.

Verbatim wording from the response
“a) Pre/New Admission Protocol – we adopted a new and thorough approach which enables our team to ensure we have all information to create a full and complete Care Plan from Day 1 and ensure all accompanying Risk Assessments are in place to support the Care Plans.”

Source location
Response from The Lakes Care Centre
Page 2 · response
Published 18 November 2025
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 monthly care-plan and risk-assessment reviews to Senior Carers and Leaders, with interim updates communicated to staff.

Verbatim wording from the response
“b) Care Plan – Reviews These are now allocated to certain key individuals (All Seniors Carers and Leaders) to ensure all are checked at least monthly and any updates added. If changes occur in between reviews then the Care Plan and Riska assessments are updated accordingly and communicated with the teams.”

Source location
Response from The Lakes Care Centre
Page 2 · response
Published 18 November 2025
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 falls protocols requiring every fall to be reported, digitally recorded and followed by reassessment when needs may have changed.

Verbatim wording from the response
“The Lakes Care Centre now has clear guidelines and protocols to follow in all falls – whether serious or apparently innocuous. The guidance now direct people to report on every occasion (using Digital health – during operating hours, NHS 11 support or NHS 999 support).”

Source location
Response from The Lakes Care Centre
Page 3 · response
Published 18 November 2025
Open published response
28 Feb2025
Birmingham and Solihull
Concerns raised1
1. Failure to update falls prevention risk assessments after falls and deterioration in condition
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Update falls risk assessments within 24 hours and document follow-up in care records.
  Stated by Care Home ManagerStated completed
2. Action
  Hold staff meetings reinforcing accurate incident assessment, timely reporting and compliance with policy and guidance.
  Stated by Care Home ManagerStated completed
3. Action
  Implement a documentation lead role to oversee falls and risk assessments, with monthly accident audits and timely responses.
  Stated by Care Home ManagerStated completed
AI-generated summary

June PHILLIPS · 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

June Phillips lived in a care home and, while taking clopidogrel, fell on 7 April 2023 and subsequently deteriorated. She was admitted to hospital on 24 April, where a CT scan confirmed a large traumatic subdural haemorrhage; she died on 30 April 2023. The substantive concerns were inaccurate care home records, failure to update fall-risk assessments, and an inadequate post-falls 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
Failure to update falls prevention risk assessments after falls and deterioration in condition
Wider context from the report
“2. The risk assessment for prevention of falls was not updated when it should have been after her fall on 07/04/23 and when her condition deteriorated. There is a concern that this create a risk of further deaths as risk assessments are not up to date. ”
Source location
June PHILLIPS · Prevention of Future Deaths report
Page 2 · concerns
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 falls risk assessments within 24 hours and document follow-up in care records.

Verbatim wording from the response
“1. The documentation following a resident having a fall in the home is as follows the falls risk assessment (screening for tools part one and part two) are updated within 24 hours this is then followed through and documented within the care records. A root analysis tool along with an incident investigation form has now been implemented.”

Source location
Response from Willow Grange Care Home
Page 1 · response
Published 3 March 2025
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
Hold staff meetings reinforcing accurate incident assessment, timely reporting and compliance with policy and guidance.

Verbatim wording from the response
“7. Staff meetings have been held following June Phillips fall where it has been discussed the importance of documenting and reporting accurately and timely. A Staff meeting took place as of 11th March 2025 to inform the staff of the Coroners Court hearing regarding June Phillips and to discuss the importance of completing an accurate assessment of each accident and incident and also reacting promptly and in accordance to policy and updated guidance.”

Source location
Response from Willow Grange Care Home
Page 1 · response
Published 3 March 2025
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 a documentation lead role to oversee falls and risk assessments, with monthly accident audits and timely responses.

Verbatim wording from the response
“14. We have implemented a lead of documentation who is responsible for checking and over seeing i.e. falls and risk assessments. All accidents are audited monthly and responded to accordingly and in a timely manner.”

Source location
Response from Willow Grange Care Home
Page 2 · response
Published 3 March 2025
Open published response
23 May2024
Inner South London
Concerns raised1
1. Failure to systematically review and update risk indicators at relevant patient events
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Adapt the risk assessment and formulation tool with the National Culture of Care team, train staff and embed sustained practice change.
  Stated by South London and Maudsley NHS Foundation TrustStated in progress
2. Action
  Issue a blue light bulletin reminding clinical staff to update risk assessment documents at appropriate intervals and during assessment.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
3. Action
  Operate a standalone risk-assessment audit tool for inpatient, crisis and community services to improve assessment quality and accuracy.
  Stated by South London and Maudsley NHS Foundation TrustStated completed
1. Action
  Conduct regular audits of risk assessments to ensure completion in accordance with requirements.
  Stated by South London and Maudsley NHS Foundation TrustStated planned
2. Action
  Include risk-assessment and safety-planning principles in national guidance for mental health inpatient services.
  Stated by NHS EnglandStated completed
Respondent positions 1
1. Position
  Specific concerns about the Trust’s electronic risk assessment tool should be addressed by Oxleas NHS Foundation Trust and NHS England.
  Stated by Department of Health and Social CareRedirects responsibility
AI-generated summary

Jada Monoja · 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

Jada Monoja, who had a history of chronic paranoid and delusional thinking, disclosed suicidal thoughts on 15 November 2020 and was assessed by mental health services before being accepted by the Home Treatment Team. In the early hours of 17 November 2020, he was found unresponsive after leaving home and could not be resuscitated; the inquest concluded that he died by suicide, likely while experiencing delusional and paranoid thoughts. The principal concerns relate to the use of the online risk assessment tool, including assessments being incomplete, insufficiently dated or signposted, and difficult to identify within chronological records.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to systematically review and update risk indicators at relevant patient events
Wider context from the report
“Multiple witnesses indicated that the Risk Assessment Tool on the online system (EPJS) is not used in line with policy (i.e. that a new assessment in that tool is undertaken at the time of each admission/discharge/major risk event etc.), and, if updated, may only be updated in so far as additional narrative is added to the last such narrative in a previously completed assessment. Further, the evidence was that rather than be used for a detailed assessment per the indicators set out in the tool at the time of each relevant event, it was reviewed to instead access any past assessment in order (only) to establish quickly a benchmark against which the gauge a patient’s current presentation when considering their risks. The detailed indicators informing the risk assessment were not updated. Although it was submitted that patient risk was nonetheless assessed and recorded in the EPJS, and acknowledged that benchmarking/comparison is useful, I am concerned that: (1) if the risk indicators set out in the tool are not systematically reviewed or reconsidered, then the assessment of risk that follows will then be based on incomplete, and therefore misleading, information; and (2) absent the above, and dating of revisions within a compound document, it is not clear on what indicators any assessment is in fact based (3) to the extent the risk assessment is used as a benchmarking tool, the impression given to the most recent reviewer is then likely to be incomplete and misleading; (4) the apparent current use of the tool to establish a point of benchmarking/comparison is in any event lost where the compound narrative assessments are not clearly dated and signposted ; (5) if the detailed patient assessment is instead placed as a new entry in the general chronological notes, the usefulness of the tool as a clear, well signposted, dated assessment and documentation of the patients of risk(s), is lost, requiring a reviewer to instead review the general chronological log of entries on the EPJS where it is not required to be articulated in the same terms, and may be more difficult to identify in a longstanding patient. ”
Source location
Jada Monoja · Prevention of Future Deaths report
Page 2 · concerns
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
Adapt the risk assessment and formulation tool with the National Culture of Care team, train staff and embed sustained practice change.

Verbatim wording from the response
“As you have noted, following the investigation into this very sad death, the Trust is committed to improving our approach to assessment, formulation and safety planning. To this effect, leads have been appointed to start this work and last month the Trust was successful in a bid to be one of the second wave pilot sites to work with the National Culture of Care team to adapt our risk assessment and formulation tool. The purpose of this is to train staff in current best practice with regards to risk, and to embed sustained change in practice across the Trust. This is a major piece of work over the next 18 months, with significant service user involvement and using quality improvement methodology. Progress will be tracked by regular meetings and review of data with the culture of care team.”

Source location
Response from South London and Maudsley NHS Trust
Page 2 · response
Published 20 May 2024
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
Issue a blue light bulletin reminding clinical staff to update risk assessment documents at appropriate intervals and during assessment.

Verbatim wording from the response
“As a result, we will be issuing a blue light bulletin to all clinical staff by Friday 9th August 2024 reminding them of the need to ensure risk assessment documents are updated at appropriate intervals including at the time of assessment in line with the Trust risk assessment policy.”

Source location
Response from South London and Maudsley NHS Trust
Page 2 · response
Published 20 May 2024
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
Operate a standalone risk-assessment audit tool for inpatient, crisis and community services to improve assessment quality and accuracy.

Verbatim wording from the response
“Teams will ensure this is being completed through regular audits of risk assessments on the Trust Audit Systems ‘Tenable’. From June 2024, the Trust has made changes to the auditing system of Risk assessments for inpatients, crisis and community services to ensure that this is a now stand-alone audit tool to ensure the quality and accuracy of risk assessments for patients within our care.”

Source location
Response from South London and Maudsley NHS Trust
Page 2 · response
Published 20 May 2024
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 audits of risk assessments to ensure completion in accordance with requirements.

Verbatim wording from the response
“Teams will ensure this is being completed through regular audits of risk assessments on the Trust Audit Systems ‘Tenable’. From June 2024, the Trust has made changes to the auditing system of Risk assessments for inpatients, crisis and community services to ensure that this is a now stand-alone audit tool to ensure the quality and accuracy of risk assessments for patients within our care.”

Source location
Response from South London and Maudsley NHS Trust
Page 2 · response
Published 20 May 2024
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
Include risk-assessment and safety-planning principles in national guidance for mental health inpatient services.

Verbatim wording from the response
“One of the key actions set out in the Government’s Suicide Prevention Strategy (published on 11 September 2023) was that NHS England would identify opportunities to improve the quality and culture of risk management and safety planning within mental health services. The position regarding risk assessments was included in the NHS England guidance to improve the culture of care for mental health inpatient services in April 2024: Culture of care standards for mental health inpatient services.”

Source location
Response from NHS England
Page 1 · response
Published 20 May 2024
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
Specific concerns about the Trust’s electronic risk assessment tool should be addressed by Oxleas NHS Foundation Trust and NHS England.

Verbatim wording from the response
“The specific details of your concerns should be addressed in the responses from the Oxleas NHS Foundation Trust and NHS England. However, we recognise the issues associated with the use of risk assessment tools in the care of people who may be at risk of suicide. The ability of clinicians to identify and manage an individual’s risk of suicide is critical to enabling treatment and longer-term support that can help to reduce suicidal risk. However, risk assessment tools and scales, used in isolation, cannot accurately predict risk of self-harm or suicide and any use of such tools must only be as part of a wider, person-centred conversation to best understand and assess an individual’s suicidal risk.”

Source location
Response from DHSC
Page 1 · response
Published 20 May 2024
Open published response
21 Feb2024
Gloucestershire
Concerns raised1
1. Failure to update risk assessments and take appropriate action following injurious medical events
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 2
1. Action
  Mandate medical review, record updating and risk-assessment updates after medical emergencies that could harm patients.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated completed
2. Action
  Audit quarterly healthcare records for evidence of post-emergency reviews and updates, and share results with the Hospital Matron.
  Stated by Gloucestershire Health and Care NHS Foundation TrustStated planned
AI-generated summary

Severine Alexia Kelly · 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

Severine Alexia Kelly, who was detained under the Mental Health Act and accommodated at Wotton Lawn Hospital, choked on a sandwich provided by hospital staff on 1 October 2022 and died at the hospital. Concerns included out-of-date training for some bank staff, inadequate updating of risk assessments after a previous choking incident, difficulties contacting emergency services, delays in paramedic attendance, uncertainty about when to call an ambulance, and an AED with an apparently non-working internal clock.

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 update risk assessments and take appropriate action following injurious medical events
Wider context from the report
“Staff needed to be aware of the need to update risk assessments and take appropriate action following a medical event that could be injurious to a patient. Specifically, Severine suffered a similar choking incident in 2021. ”
Source location
Severine Alexia Kelly · Prevention of Future Deaths report
Page 1 · concerns
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
Mandate medical review, record updating and risk-assessment updates after medical emergencies that could harm patients.

Verbatim wording from the response
“We have shared the outcome of the hearing with all clinical staff at Wotton Lawn Hospital and have produced a practice notice to remind clinical colleagues that, following a medical emergency, the event is reviewed by the medical team/ward Doctor. I can confirm that this has been circulated throughout the site and discussed at team meetings. The notice mandates that following a medical event that has the potential to harm a patient, an entry must be made in the patient record, the medical history and any relevant risk assessment must be updated. The Practice Notice is included as Appendix 1. We will also complete a quarterly audit to ensure that we can evidence this in the healthcare record and the result will be shared with the Hospital Matron.”

Source location
Response from Gloucestershire Health and Care NHS Foundation Trust
Page 2 · response
Published 23 February 2024
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit quarterly healthcare records for evidence of post-emergency reviews and updates, and share results with the Hospital Matron.

Verbatim wording from the response
“We have shared the outcome of the hearing with all clinical staff at Wotton Lawn Hospital and have produced a practice notice to remind clinical colleagues that, following a medical emergency, the event is reviewed by the medical team/ward Doctor. I can confirm that this has been circulated throughout the site and discussed at team meetings. The notice mandates that following a medical event that has the potential to harm a patient, an entry must be made in the patient record, the medical history and any relevant risk assessment must be updated. The Practice Notice is included as Appendix 1. We will also complete a quarterly audit to ensure that we can evidence this in the healthcare record and the result will be shared with the Hospital Matron.”

Source location
Response from Gloucestershire Health and Care NHS Foundation Trust
Page 2 · response
Published 23 February 2024
Open published response
5 Feb2024
Essex
Concerns raised1
1. Failure to update risk assessments after alcohol consumption incidents
This report raised 8 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 1
1. Action
  Complete leave risk assessments, offer post-leave engagement, record incidents through Datix, update risk assessments, and share relevant information with involved professionals.
  Stated by Essex Partnership University NHS Foundation TrustStatus unclear
AI-generated summary

Georgia Dehaney-Perkins · 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

Georgia Dehaney-Perkins was found deceased on 6 September 2022 on Latton Common, Harlow, after a history of mental health difficulties, self-harm and suicidal ideation. The medical cause of death was recorded as combined alcohol and drug toxicity. Concerns included the suitability and safety of her ward bathroom, incomplete risk assessment and incident recording, insufficient documentation and communication about medication and alcohol risks, and a lack of action after family raised concerns about her leaving home with medication.

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 update risk assessments after alcohol consumption incidents
Wider context from the report
“(2) Medication was appropriately withheld on 28 August when Ms Dehaney-Perkins returned to the ward intoxicated due to potential interaction with alcohol that can cause increased sedation, (3) arrhythmia and fatality. a. This risk of consuming alcohol with her specific medication was not discussed with the Ms Dehaney-Perkins or family. b. Not all incidents of consumption of alcohol on return from leave were recorded and risk assessments were not updated. c. Ms Dehaney-Perkins had agreed to mitigations of medication management by her family that were not recorded on the care plan on discharge on 2 September. Ms Dehaney-Perkins demanded control of her medication on 4 September against concerns of her family who were forced to return medication. ”
Source location
Georgia Dehaney-Perkins · Prevention of Future Deaths report
Page 3 · concerns
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 leave risk assessments, offer post-leave engagement, record incidents through Datix, update risk assessments, and share relevant information with involved professionals.

Verbatim wording from the response
“A risk assessment is completed prior to a patient going on leave. Upon the patient returning from leave one to one engagement is offered to the patient, if any incident has occurred whilst the patient has been on leave this is reported via Datix and the risk assessment is updated accordingly. The incident is also documented within the patients’ notes and information is shared with all health professionals involved in the care of the patient during handover, Multidisciplinary Team meetings and ward reviews.”

Source location
Response from Essex Partnership University NHS Foundation Trust
Page 2 · response
Published 14 February 2024
Open published response
20 Nov2023
South Yorkshire (Western)
Concerns raised1
1. Failure to routinely check and update risk assessments
This report raised 4 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Continue reinforcing risk-assessment review and updating through supervision, and monitor compliance through clinical and record-keeping audits.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated in progress
2. Action
  Audit clinical record keeping, including risk assessments and discharge summaries.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated completed
3. Action
  Use live community-team dashboards to identify when key documents require review, revision or updating.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated completed
1. Action
  Assess the feasibility of extending live risk-document dashboards to other services.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated in progress
2. Action
  Conduct biannual Trust-wide audits of compliance with risk-assessment requirements.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated planned
3. Action
  Scope development of a new clinical risk-assessment tool within the electronic patient record programme.
  Stated by Sheffield Health Partnership University NHS Foundation TrustStated in progress
AI-generated summary

Gareth Michael Etchells-Heights · 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

Gareth Michael Etchells-Heights experienced deteriorating mental health and psychosis before being admitted to hospital and later moved to a step-down bed at Wainwright Crescent. He died there in the early hours of 24 April 2022 after tying a ligature, with the inquest recording asphyxiation by ligature. Substantive concerns included inadequate discharge information, inconsistent review of medical notes, failure to update risk assessments, and inadequate record keeping.

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 routinely check and update risk assessments
Wider context from the report
“3. Failure to update risk assessment There was a failure to update Gareth’s risk assessment, which at the date of his death was last updated on 7 April 2022. Gareth’s psychotic state had materially changed since 7 April 2022, and so the risk assessment effectively became redundant by virtue of the failure to update it. This impacted upon the ability of those caring for Gareth to identify and recognise changes in his behaviour that were triggers for acute mental health crisis or suicidal behaviours. In evidence it became apparent that the Trust did not have a system in place for routinely checking and updating the risk assessments. ”
Source location
Gareth Michael Etchells-Heights · Prevention of Future Deaths report
Page 3 · concerns
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
Continue reinforcing risk-assessment review and updating through supervision, and monitor compliance through clinical and record-keeping audits.

Verbatim wording from the response
“Our training currently focuses on the importance of reviewing and updating risk assessments, we will continue to deliver these key messages through supervision and monitor through clinical audit, recognising that clinical audit is a snapshot of overall caseloads. Audit will also take place through individual clinical supervision at team level as part of the record keeping requirements.”

Source location
Response from Sheffield Health and Social Care
Page 2 · response
Published 12 December 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Audit clinical record keeping, including risk assessments and discharge summaries.

Verbatim wording from the response
“The Clinical Director for Acute and Community Services has provided instruction via email to all inpatient Responsible Clinicians that diagnoses must be captured in Insight (our electronic patient record system) to enable them to be pulled through onto the discharge summary. Discussions have taken place regarding the purpose of discharge summaries and the misunderstanding of their use. We commissioned 360 Assurance, our internal auditors, to undertake an audit of our clinical record keeping, including risk assessments and discharge summaries. This audit was completed in May 2024. From the findings of the audit and the new national guidance that was issued in January 2024, we have agreed to review the format and function of our discharge summaries to include early warning signs of deterioration.”

Source location
2023-0517 Response from Sheffield Health and Social Care - Update
Page 1 · response
Published 12 December 2023
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
Use live community-team dashboards to identify when key documents require review, revision or updating.

Verbatim wording from the response
“Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update. We are currently considering the feasibility of developing these dashboards for other services. The internal audit of record keeping highlighted the need to ensure that the ‘clinical risk and management of harm policy’ has a clear governance route for reviewing audits of compliance for risk assessments, which will take place biannually across the Trust. A formal report will be presented biannually on progress with clinical record keeping and clinical risk assessment improvements to the Quality Assurance Committee, a sub-committee of the Board of Directors.”

Source location
2023-0517 Response from Sheffield Health and Social Care - Update
Page 2 · response
Published 12 December 2023
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
Assess the feasibility of extending live risk-document dashboards to other services.

Verbatim wording from the response
“Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update. We are currently considering the feasibility of developing these dashboards for other services. The internal audit of record keeping highlighted the need to ensure that the ‘clinical risk and management of harm policy’ has a clear governance route for reviewing audits of compliance for risk assessments, which will take place biannually across the Trust. A formal report will be presented biannually on progress with clinical record keeping and clinical risk assessment improvements to the Quality Assurance Committee, a sub-committee of the Board of Directors.”

Source location
2023-0517 Response from Sheffield Health and Social Care - Update
Page 2 · response
Published 12 December 2023
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 biannual Trust-wide audits of compliance with risk-assessment requirements.

Verbatim wording from the response
“Live dashboards have been developed for use by our community teams. These dashboards show staff at any given point in time when key documents were updated and what requires their attention to review, revise or update. We are currently considering the feasibility of developing these dashboards for other services. The internal audit of record keeping highlighted the need to ensure that the ‘clinical risk and management of harm policy’ has a clear governance route for reviewing audits of compliance for risk assessments, which will take place biannually across the Trust. A formal report will be presented biannually on progress with clinical record keeping and clinical risk assessment improvements to the Quality Assurance Committee, a sub-committee of the Board of Directors.”

Source location
2023-0517 Response from Sheffield Health and Social Care - Update
Page 2 · response
Published 12 December 2023
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
Scope development of a new clinical risk-assessment tool within the electronic patient record programme.

Verbatim wording from the response
“In addition, as part of the new electronic patient record development, key clinical leaders will be scoping the development of a new clinical risk assessment tool.”

Source location
2023-0517 Response from Sheffield Health and Social Care - Update
Page 2 · response
Published 12 December 2023
Open published response
2 Oct2023
Birmingham and Solihull
Concerns raised1
1. Failure to complete or update risk assessments adequately
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Provide protected dedicated staff time to update risk assessment documentation.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
2. Action
  Operate a project group reviewing the risk assessment process, outpatient clinics and documentation for care support patients.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated in progress
3. Action
  Complete the review of the risk management policy.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated completed
1. Action
  Ratify the revised risk management policy.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated planned
2. Action
  Monitor risk-assessment completion through monthly local clinical governance committees and the trust-wide performance delivery group.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustStated planned
Respondent positions 1
1. Position
  The Trust disputes that failing to update risk assessment information already recorded would create a risk of death or meet the PFD threshold.
  Stated by Birmingham and Solihull Mental Health NHS Foundation TrustDisputes the concern
AI-generated summary

Paula LENIHAN · 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

Paula Lenihan was found deceased at her home on 6 March 2023. The medical cause of death was ischaemic and hypertensive heart disease, with combined toxicity from drugs in her system. The principal concern was that risk assessments within the Birmingham & Solihull Mental Health NHS Foundation Trust were not being completed or updated satisfactorily, creating a risk from insufficient recording of risk information.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to complete or update risk assessments adequately
Wider context from the report
“1. The evidence given on behalf of the Birmingham & Solihull Mental Health NHS Foundation Trust was that in addition to this present case, where the deceased's risk assessment was not updated between November 2021 and her death in March 2023 despite circumstances which I was told ought to have triggered an update, there were a further number of cases within the Trust in which Root Cause Analysis reports had been produced, where it had also been found that risk assessments were not being completed in line with expectations; further, that it was not clear why this was happening. 2. If risk assessments are not being properly completed or updated, then there is an obvious risk of deaths occurring in the future, as a result of insufficient recording of risk. The fact that risk-relevant information may be recorded in the body of clinical notes is not reassuring, because a risk assessment or risk summary ought to capture the most salient risk information so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure. 3. The evidence given to me was that a 'task and finish group' has been set up to address the issue, which expects to have concluded by early next year, i.e. 2024, and that this group will be addressing matters as they are found rather than waiting until the final stage of its existence early next year. The evidence was that this group is at an early stage, with meetings considering the terms of reference and also, recently, the most appropriate persons to contribute to the group. 4. In the circumstances I am concerned that currently there is an extant issue within the Trust about the completion of risk assessments being, on a number of occasions, unsatisfactory. The task and finish group is at an early stage and I do not know what it is going to do, or when. I therefore cannot be reassured that the issues around risk recording which that group is going to examine have, at this point in time, been addressed. It seems to me that they continue to exist, because there has been no evidence to tell me otherwise. ”
Source location
Paula LENIHAN · Prevention of Future Deaths report
Page 2 · concerns
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
Provide protected dedicated staff time to update risk assessment documentation.

Verbatim wording from the response
“The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .”

Source location
Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023
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
Operate a project group reviewing the risk assessment process, outpatient clinics and documentation for care support patients.

Verbatim wording from the response
“The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .”

Source location
Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023
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 the review of the risk management policy.

Verbatim wording from the response
“The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .”

Source location
Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023
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
Ratify the revised risk management policy.

Verbatim wording from the response
“The Trust has worked closely with teams, supporting with protected dedicated time for staff to update risk assessment documentation. A project Group has been set up to look at our risk assessment process. This has already met 4 times in recent months and includes a review of our medical out patient clinics and whether the current risk documentation process is fit for purpose, for our care support patients who are reviewed in these clinics. The review of our risk management policy is also complete and the revised policy will be ratified shortly. This work is being led by our Deputy Medical Director for Quality and Safety .”

Source location
Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023
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 risk-assessment completion through monthly local clinical governance committees and the trust-wide performance delivery group.

Verbatim wording from the response
“To ensure we continue to support staff in maintaining these levels of completion we will be monitoring via our monthly local CMHT clinical governance committee and trust wide performance delivery group.”

Source location
Response from Birmingham and Solihull Mental Health
Page 2 · response
Published 6 October 2023
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
The Trust disputes that failing to update risk assessment information already recorded would create a risk of death or meet the PFD threshold.

Verbatim wording from the response
“I understand that during evidence presented at the inquest you concluded that the failure to update the risk assessment did not contribute to the death and accepted that the information was recorded within the records for staff to access. Your report sets out your belief that the risk assessment should be updated ‘so that a professional looking quickly can absorb it; this is all the more important where professionals are under time pressure.’ This aspect of your report is not based on evidence heard at the inquest and the Trust does not accept that failing to update the Risk Assessment section of the medical notes, when the information is already within the records, would result in death. Even in times of pressure, clinicians would review all the necessary pertinent information prior to reviewing a patient.”

Source location
Response from Birmingham and Solihull Mental Health
Page 1 · response
Published 6 October 2023
Open published response
11 Aug2023
Inner North London
Concerns raised1
1. Failure to update care plans and risk assessments in light of significant developments
This report raised 5 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

Doris Irene URCH · 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

Doris Irene Urch, aged 90, fell at a care home on 6 February 2023 after support was not offered while she was ambulating. She sustained an acute left frontal intracranial haemorrhage and died on 28 February 2023. Concerns included inadequate fall-risk assessment and care planning, staff unfamiliarity with the care plan, failure to update it after an earlier fall, and inadequate preservation of historical care plans.

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 update care plans and risk assessments in light of significant developments
Wider context from the report
“(4) The care plan/risk assessment was not updated in light of a fall in November/December 2022. I was concerned that potentially significant developments might not be being taken into account in keeping the care plan under review. ”
Source location
Doris Irene URCH · Prevention of Future Deaths report
Page 3 · concerns
Open source report
9 Feb2023
Worcestershire
Concerns raised1
1. Failure to update residents’ falls risk assessment and care plan documentation following falls
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Amend monthly clinical governance meetings to review each resident’s falls and falls history.
  Stated by Barchester Healthcare LimitedStated completed
2. Action
  Introduce a regional falls champion forum chaired by divisional clinical lead nurses.
  Stated by Barchester Healthcare LimitedStated completed
3. Action
  Deliver refresher training at Latimer Court on completing documentation, including risk-related detail and timely updates.
  Stated by Barchester Healthcare LimitedStated planned
1. Action
  Develop Latimer Court checklists or prompts with the Clinical Development Nurse in line with the Falls Management Policy.
  Stated by Barchester Healthcare LimitedStated planned
Respondent positions 1
1. Position
  The identified practice matters were unlikely to have affected the resident’s outcome.
  Stated by Barchester Healthcare LimitedDisputes the concern
AI-generated summary

Bridget GORMLEY · 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

Bridget Gormley fell at her care home in Worcester on 20 July 2022 and was found to have significant traumatic intracranial bleeding. She was transferred to Worcestershire Royal Hospital, where she died on 31 July 2022. The principal concerns were that her falls risk assessment and care plan were not updated after repeated falls, and that staff may not have understood their duties to update residents’ documentation.

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 update residents’ falls risk assessment and care plan documentation following falls
Wider context from the report
“(1) During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court’s registered home manager, ████████, conceded in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care plan document were updated following any of these falls, and that they should have been so updated. This meant that: (a) Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that she presented an increased risk of suffering a fall; and (b) Measures to mitigate that increased risk were not considered. Such measures could have included: (i) Asking a GP to refer Mrs. Gormley to the falls clinic; (ii) Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising; (iii) Referring her to Occupational Therapy for mobility aids such as a walking stick or frame; (iv) Briefing staff at Latimer Court to intervene whenever Mrs. Gormley was seen mobilising by herself, and to offer her assistance. (2) ████████ was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents’ documentation in such circumstances. ”
Source location
Bridget GORMLEY · Prevention of Future Deaths report
Page 2 · concerns
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
Amend monthly clinical governance meetings to review each resident’s falls and falls history.

Verbatim wording from the response
“entered onto the clinical governance system within 24 hours. To address this, we have amended our monthly clinical governance meeting requirements to include a review of falls for any one individual and their falls history. These meetings are minuted and require discussion of residents having a fall or found on the floor in line with Barchester’s Falls Management Policy to ensure that all measures are in place to mitigate the risk of further falls and that the relevant Healthcare Professionals and equipment is accessed and utilised. We have also introduced a regional falls champion forum, chaired by our Divisional clinical lead nurses. This will have an emphasis on prevention but also include reviews of individuals who have fallen, and the documentation required to support them and plan for their needs.”

Source location
Response from Barchester Healthcare
Page 3 · response
Published 14 April 2023
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 a regional falls champion forum chaired by divisional clinical lead nurses.

Verbatim wording from the response
“entered onto the clinical governance system within 24 hours. To address this, we have amended our monthly clinical governance meeting requirements to include a review of falls for any one individual and their falls history. These meetings are minuted and require discussion of residents having a fall or found on the floor in line with Barchester’s Falls Management Policy to ensure that all measures are in place to mitigate the risk of further falls and that the relevant Healthcare Professionals and equipment is accessed and utilised. We have also introduced a regional falls champion forum, chaired by our Divisional clinical lead nurses. This will have an emphasis on prevention but also include reviews of individuals who have fallen, and the documentation required to support them and plan for their needs.”

Source location
Response from Barchester Healthcare
Page 3 · response
Published 14 April 2023
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 refresher training at Latimer Court on completing documentation, including risk-related detail and timely updates.

Verbatim wording from the response
“(j) As part of the lessons learnt as identified by the General Manager at Latimer Court it was highlighted that staff required further training from the organisation’s Clinical Development Nurse in the approach to and completion of documentation. Specifically, when to complete documentation and the requisite detail to be included in the entries into documentation. Following completion of the inquest and receipt of the Regulation 28 Report, the Managing and Regional Directors have made arrangements for further refresher training to be delivered at Latimer Court with follow up by the Regional Manager and Quality”

Source location
Response from Barchester Healthcare
Page 3 · response
Published 14 April 2023
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Develop Latimer Court checklists or prompts with the Clinical Development Nurse in line with the Falls Management Policy.

Verbatim wording from the response
“Any checklists or prompts to be used at Latimer Court by the home team will be developed in liaison with the Clinical Development Nurse and will follow the requirements of the Falls Management Policy as to actions to be taken. As part of the training staff will be required to review the environment in which the residents live, practice writing risk assessments and consider how residents needs and risks may change and to develop professional curiosity about residents’ presentation and any referrals and actions that should flow from a falls incident.”

Source location
Response from Barchester Healthcare
Page 4 · response
Published 14 April 2023
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
The identified practice matters were unlikely to have affected the resident’s outcome.

Verbatim wording from the response
“Following this very sad incident we have made a number of changes to the provision of care and services at Latimer Court, and these have been adopted across the organisation in other services and divisions where appropriate. For the purpose of this response, we have considered the concerns raised by you and where possible we have grouped together details of assurance measures where these appear to deal with more than one area of concern. Whilst it is unlikely that the matters referred to below would have affected the outcome for Mrs Gormley, there are matters of practice identified where the need for improvement has been recognised and dealt with.”

Source location
Response from Barchester Healthcare
Page 1 · response
Published 14 April 2023
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Failure to maintain collaborative, complete and accurate risk assessments and care plans

Concerns raised1

Failure to complete and update falls risk assessments after falls

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to update falls prevention risk assessments after falls and deterioration in condition

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.3

Concerns raised1

Failure to systematically review and update risk indicators at relevant patient events

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.5

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised1

Failure to update risk assessments and take appropriate action following injurious medical events

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.2

Concerns raised1

Failure to update risk assessments after alcohol consumption incidents

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to routinely check and update risk assessments

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.6

Actions described in response 3

Actions described in response 3

Actions described in response 5

Respondent positions 1

Actions described in response 2

Actions described in response 1

Actions described in response 6