18 Jun 2025 Margaret Elizabeth DOUGLAS · Prevention of Future Deaths report Cheshire
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Concerns raised 1
Failure to ensure provision of required one-to-one care before accepting care responsibilities View source
This report raised 2 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Margaret Elizabeth DOUGLAS · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Margaret Elizabeth Douglas suffered recurrent falls, a subdural haemorrhage, worsening stroke symptoms and increasing frailty while receiving care, and died after a further deterioration at Holcroft Grange. Concerns included accepting her into care despite being unable to provide the required one-to-one supervision, and using carers whose understanding of her complex needs and ability to communicate effectively were questioned, particularly given her risk of aspiration.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure provision of required one-to-one care before accepting care responsibilities
Wider context from the report “i) In the course of the Inquest I heard evidence that by the 5th September 2024, Holcroft Grange had already identified that they were unable to meet Elizabeth's needs, considering that she required one to one care. Despite being aware that they were unable to meet Elizabeth's needs and that they were unable to provide one to one care , Holcroft Grange accepted Elizabeth back into their care , following which she suffered a further fall. Agreeing to provide care for an individual in circumstances where it is known that the level of care that person requires to keep them safe cannot be provided , creates a risk that future deaths could occur as a consequence of inadequate care and supervision.
” Source location Margaret Elizabeth DOUGLAS · Prevention of Future Deaths report
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind managers to escalate refusals of required one-to-one care to Head Office and the oversight team.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess and provide interim one-to-one care using the organisation’s workforce while external funding is pursued.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The suggestion that providers can fund one-to-one care and reclaim costs from local authorities does not reflect the provider’s experience.
Verbatim wording from the response “I note in court, that the local authority stated that as a provider we could have put a 1-1 in place and then claimed back the monies later down the line. However, this suggestion is just not my experience or our company’s experience of working with local authorities and I can highlight several cases whereby we are pursuing funds for such cases via the courts.” Source location Response from Minster Care Group
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation One-to-one care cannot continue indefinitely without local-authority funding; if funding is refused, the resident may need to leave the home.
Verbatim wording from the response “3) The organisation has reminded all managers (via email) that should 1-1 care be required, but refused by the third party (usually a local authority), this refusal should be escalated to our Head Office and oversight team for assistance & support to resolve the issue. This matter will then be taken up by our Operations Team to ensure that the 1-1 care is assessed further and then provided until funding from the Local Authority can be secured. This will ensure that appropriate levels of care provided while we await a substantive response from the Local Authority (or other relevant third-party organisation). We plan to do this by utilising our own workforce in the interim period. Should the funding not be forthcoming and any requests for assistance be refused, a notice will be served to the Local Authority for the resident to leave the home.” Source location Response from Minster Care Group
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Concerns raised 2
Failure to assess relevant patient-care information before accepting transfer View source Failure to ensure receipt of all relevant patient-care information before transfer View source
Linked responses
Betsi Cadwaladr University LHB Highfield Care Home, Wrexham
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 7
Highfield Care Home, Wrexham
Conduct all pre-admission assessments in person, except for emergency admissions.
View source
Highfield Care Home, Wrexham
Update the pre-admission assessment document with prompts to obtain all required information, including diabetes information.
View source
Betsi Cadwaladr University LHB
Establish a Task and Finish Group of Community Hospital Matrons and Discharge Nurses to review the care-home discharge plan form.
View source
Betsi Cadwaladr University LHB
Review the care-home discharge plan form to define observation and medication frequencies clearly.
View source
Betsi Cadwaladr University LHB
Share the finalized and approved form changes with the North Wales Care Home Forum.
View source
Betsi Cadwaladr University LHB
Share the new form and supporting examples with teams through Team Meeting Safety Briefs.
View source
Betsi Cadwaladr University LHB
Develop audit questions, complete peer-review monitoring, and report findings through monthly Matron Reports to local quality groups.
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Patricia Ann Catterall · 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 Ann Catterall’s care was transferred to a nursing home on 11 June 2024 after 207 days at Mold Community Hospital. Her blood sugar levels, previously checked three times daily, were checked once daily at the nursing home; her condition deteriorated and she was admitted to hospital on 19 June with HHS and sepsis, dying a few days later. The principal concern was that the nursing home’s pre-transfer assessment was not sufficiently robust and did not identify all relevant care information, including the frequency of her blood sugar monitoring.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess relevant patient-care information before accepting transfer
Wider context from the report “That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care .
Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided.
In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of Health Board .
” Source location Patricia Ann Catterall · Prevention of Future Deaths report
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to ensure receipt of all relevant patient-care information before transfer
Wider context from the report “That the process of assessment by the Nursing Home prior to the transfer of care to them was not sufficiently robust so as to ensure that all relevant information required for the safe care of a patient had been received and assessed prior to the patient being received into their care.
Evidence was received that in the majority of cases (post Covid) there are no face to face assessments prior to patient transfer and that the assessment is therefore dependent on the documentation supplied to the Nursing Home by the Health Board which in some cases may result in not all relevant information being provided .
In this instance evidence was given that the Nursing Home did not know that the deceased’s blood sugar levels were monitored three times per days whilst in the care of Health Board.
” Source location Patricia Ann Catterall · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct all pre-admission assessments in person, except for emergency admissions.
Verbatim wording from the response “1. All pre-admission assessments are now being conducted in person except for emergency admissions.” Source location Response from Pendine Park Care Organisation
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Update the pre-admission assessment document with prompts to obtain all required information, including diabetes information.
Verbatim wording from the response “2. Our pre-admission assessment document has been updated and includes prompts to ensure all information is requested prior to admission, this includes a section for diabetes, see attached pre-admission assessment document.” Source location Response from Pendine Park Care Organisation
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish a Task and Finish Group of Community Hospital Matrons and Discharge Nurses to review the care-home discharge plan form.
Verbatim wording from the response “A Task and Finish Group has been set up (consisting of Community Hospital Matrons and Discharge Nurses) to review the current form for suitability, and this work will specifically ensure that frequency of observations and medication is clearly defined within the document.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review the care-home discharge plan form to define observation and medication frequencies clearly.
Verbatim wording from the response “In response to the notice, our senior nursing team in the East Integrated Health Community have led work to understand the issue across the Health Board. This work has identified that whilst there is a standardised form for discharge plans into care homes, the level of detail is varied.” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the finalized and approved form changes with the North Wales Care Home Forum.
Verbatim wording from the response “Changes to the form, once finalised and approved, will be shared with the North Wales Care Home Forum, with support from the Quality Development Team (this team supports improvements in quality across commissioned care home services).” Source location Response from Betsi Cadwaladr University Health Board
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Share the new form and supporting examples with teams through Team Meeting Safety Briefs.
Verbatim wording from the response “The new form, and examples to support learning, will be shared with teams and will be included on Team Meeting Safety Briefs.” Source location Response from Betsi Cadwaladr University Health Board
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop audit questions, complete peer-review monitoring, and report findings through monthly Matron Reports to local quality groups.
Verbatim wording from the response “Audit questions will be developed to monitor these changes which will be completed by Ward Managers and Matrons and included in the peer reviews across our services. The audit findings will be included in the monthly Matron Reports into local quality groups for assurance.” Source location Response from Betsi Cadwaladr University Health Board
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21 Mar 2024 Alan Richard Miles Davies · Prevention of Future Deaths report South Wales Central
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Concerns raised 1
Insufficient assessment of whether needs are too complex for HMP Cardiff View source
This report raised 12 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Alan Richard Miles Davies · 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
Alan Richard Miles Davies was transferred to HMP Cardiff after 16 days of refusing food and was found collapsed in his cell 10 days later; he later died in hospital. The reported concerns included inadequate communication and handover of information, insufficient care planning and observation, the absence of a food and fluid refusal policy, inadequate staffing, and missed opportunities to escalate his care.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Insufficient assessment of whether needs are too complex for HMP Cardiff
Wider context from the report “(4) Insufficient consideration was given to whether Mr Davies’ needs were too complex to be met by HMP Cardiff .
” Source location Alan Richard Miles Davies · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop and establish a standard operating procedure for communicating health information and determining appropriate placement before transfers to HMP Cardiff.
Verbatim wording from the response “Regarding communication pathways, collaborative efforts with relevant parties have led to the development of a Standard Operating Procedure (SOP) for transferring individuals with mental/physical health needs into our care. This SOP delineates the necessary information required by HMP Cardiff to assess the individual's health needs and outlines a reliable route for sharing information across organisations to mitigate information-related risks. The protocol also identifies” Source location Response from Cardiff and Vale University Health Board
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Concerns raised 1
Failure to assess patients' needs and required measures during the admission process View source
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Harold Blackshaw · 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
Harold Blackshaw died from COVID-19 on 1 March 2021 after falls, a fractured neck of femur, hip dislocations, surgery and subsequent admissions to hospital and care homes. The report raised concern that Grange Ward lacked an admission process to assess patients’ individual needs and put appropriate falls-prevention measures in place.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to assess patients' needs and required measures during the admission process
Wider context from the report “During the course of the inquest evidence was given regarding the admission process for patients admitted to the Haywood Hospital. Specifically the rehabilitation ward which Mr Blackshaw was admitted to (“Grange Ward”). It was heard that this ward was primarily for the rehabilitation of elderly patients that were recovering from injuries; some after falls. Some patients were high risk of falls. The evidence given suggested that there was no admission process which assessed the needs of each patient and what measures should be put in place to meet their needs, before they came to the ward, or when they were on the ward . This gives me concern that a future death could result.
” Source location Harold Blackshaw · Prevention of Future Deaths report
Open source report
Concerns raised 1
Failure to physically inspect accommodation suitability before placement View source
Linked responses
Care Quality Commission Devon Partnership NHS 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
Devon Partnership NHS Trust
Inspect new provider facilities before contracting to assure placement suitability.
View source
Devon Partnership NHS Trust
Complete a social care delivery redesign with dedicated community mental health social workers responsible for sourcing and reviewing placements.
View source
Devon Partnership NHS Trust
Link community and forensic social work teams to standardise placement sourcing and review and ensure proposed placements reach the contract and review team before contracting.
View source
Devon Partnership NHS Trust
Develop an out-of-area placement protocol and provider monitoring form covering suitability assurances and face-to-face reviews.
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Glenn Macmartin · 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
Glenn Macmartin had Bipolar Disorder and an Acquired Brain Injury and required specific care and accommodation. He was placed in a privately owned care home, where concerns were raised about care and suboptimal note keeping; the home later closed. He was admitted to hospital and died there on 1 April 2019.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to physically inspect accommodation suitability before placement
Wider context from the report “(1) The deceased was accommodated in a Care Home that was subsequently formally closed due to poor service.
The selection of the accommodation was made without a physical inspection of its suitability for the deceased by the organisation with responsibility for providing the accommodation before the deceased took up residence.
” Source location Glenn Macmartin · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Inspect new provider facilities before contracting to assure placement suitability.
Verbatim wording from the response “In line with the evidence set given by ████████ at the Inquest, in the time since Mr MacMartin’s death, a decision has been made that mental health social care will not contract with new providers without visiting the facilities to gain assurance of suitability.” Source location Response-from-Wonford-House-Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete a social care delivery redesign with dedicated community mental health social workers responsible for sourcing and reviewing placements.
Verbatim wording from the response “• A redesign of social care delivery within the Trust is now complete, with dedicated social workers in each community mental health team, who are responsible for both the sourcing and review of social care placements and support;” Source location Response-from-Wonford-House-Hospital
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How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Link community and forensic social work teams to standardise placement sourcing and review and ensure proposed placements reach the contract and review team before contracting.
Verbatim wording from the response “• The community social work managers have linked with the forensic social work team at Langdon Hospital (a secure service for which the Trust is responsible, and where Mr MacMartin had been detained) to strengthen links and ensure that processes and practice relating to the sourcing and review of social care is uniform across all services and that the contract and review team are fully cited on all proposed placements prior to any contracting taking place;” Source location Response-from-Wonford-House-Hospital
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop an out-of-area placement protocol and provider monitoring form covering suitability assurances and face-to-face reviews.
Verbatim wording from the response “• A protocol to specifically address the placing of people outside of the Trust’s geographical area has been developed. This will strengthen our existing practice by providing a clear guide for our teams and follows the guidance within the advice note for directors and of adult social services commissioning out of area care and support services produced by ADASS. It also highlights the need to ensure the provider has arrangements in place and contains provisions to assure of suitability of service and face to face reviews. The Trust has also developed an Out of County Care Provider Monitoring form as part of its provider assurance service. I attach the protocol and Monitoring form for your information.” Source location Response-from-Wonford-House-Hospital
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The local authority has a role in selecting and monitoring care services, including safeguarding, and is expected to address that role.
Verbatim wording from the response “We recognise that the Local Authority also has a role in selection and monitoring of a service, as well as in relation to safeguarding. We anticipate the Local Authority will summarise this role in their response to the Regulation 28 report.” Source location Response from CQC
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing CQC ratings, contractual quality provisions and placement experience were considered sufficient assurance that the care home was appropriate.
Verbatim wording from the response “The Trust does reasonably rely on the inspections and ratings provided by the CQC in terms of quality assurance and adherence to any relevant regulations. I understand that at the time of Mr MacMartin’s placement at Annette’s Care Home (“the Care Home”) in Plymouth the corresponding CQC report was reviewed. It was confirmed that the Care Home was rated by the CQC as “Good”. Furthermore, at the time Devon County Council had an existing contract in place with the Care Home. The contract for services entered into included the following provisions around quality assurance:” Source location Response-from-Wonford-House-Hospital
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4 May 2020 Barry Wayne Preston · Prevention of Future Deaths report Manchester South
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Concerns raised 1
Placement without a clear understanding of the person's needs View source
This report raised 9 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked responses
Bolton Borough Council Bolton NHS Foundation Trust Department of Health and Social Care Greater Manchester Mental Health NHS Foundation Trust
Stated actions An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised. 8
Bolton NHS Foundation Trust
Develop a competency framework for identifying and assessing patients with complex health, social and onward care needs.
View source
Bolton NHS Foundation Trust
Develop a Home First competency framework for recommending appropriate intermediate-care placements.
View source
Bolton NHS Foundation Trust
Review transfers to intermediate care daily through an Integrated Discharge Team nurse.
View source
Bolton NHS Foundation Trust
Require ward managers to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before transfer of care.
View source
Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust
Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
View source
Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust
Develop a skills and competency framework for Integrated Discharge Team members to identify patients with complex onward needs.
View source
Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust
Deliver additional training to existing Integrated Discharge Team staff on identifying patients with complex onward needs.
View source
Bolton Borough Council and Bolton NHS Foundation Trust and Greater Manchester Mental Health NHS Foundation Trust
Require wards to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before considering transfer of care.
View source See 5 more actions
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AI-generated summary
Barry Wayne Preston · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Placement without a clear understanding of the person's needs
Wider context from the report “7. His placement at Laburnum Lodge was made without a clear understanding of his needs . He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.
” Source location Barry Wayne Preston · Prevention of Future Deaths report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a competency framework for identifying and assessing patients with complex health, social and onward care needs.
Verbatim wording from the response “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a Home First competency framework for recommending appropriate intermediate-care placements.
Verbatim wording from the response “The Home First team are a therapy based team which aims to support those patients in the ED and assessment wards to return home without a longer period of hospital admission. It has been identified that there is a skills gap within this team and a competency framework has been developed to support staff in making the appropriate recommendation for placement at intermediate care units. In order to ensure all transfers are safe these will be reviewed on a daily basis by a member of the nursing team within the IDT.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Review transfers to intermediate care daily through an Integrated Discharge Team nurse.
Verbatim wording from the response “The Home First team are a therapy based team which aims to support those patients in the ED and assessment wards to return home without a longer period of hospital admission. It has been identified that there is a skills gap within this team and a competency framework has been developed to support staff in making the appropriate recommendation for placement at intermediate care units. In order to ensure all transfers are safe these will be reviewed on a daily basis by a member of the nursing team within the IDT.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require ward managers to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before transfer of care.
Verbatim wording from the response “• Ward Managers have been instructed that any patient with complex needs should be escalated to the IDT for a full MDT meeting where any transfer of care is being considered.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.
Verbatim wording from the response “At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in-reach model which was reliant on other professionals identify those patients who had existing social care needs prior to admission to hospital. The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Develop a skills and competency framework for Integrated Discharge Team members to identify patients with complex onward needs.
Verbatim wording from the response “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 Response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver additional training to existing Integrated Discharge Team staff on identifying patients with complex onward needs.
Verbatim wording from the response “As a combined service it has been identified that there are a number of skills and competencies which all members of the team will need to have in order to identify those patients with complex onward needs. The development is underway but has not been finalised due to the COVID-19 Response. Additional training of existing staff is being undertaken and will be completed by the end of August 2020.” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require wards to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before considering transfer of care.
Verbatim wording from the response “Actions taken by Bolton Council and BNFT” Source location 2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Local Authority will provide a further response on actions concerning safe placement and transfers of care.
Verbatim wording from the response “Section 5 (7): His placement at Laburnum Lodge was made without clear understanding of his needs. He fell twice within 24 hours sustaining a further bleed to his brain and readmission to the acute hospital.” Source location 2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.
Verbatim wording from the response “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.” Source location 2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
Open published response
15 Nov 2019 Mary Josephine Hoare · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 1
Reliance on applicant and family information when assessing privately funded applicants View source
This report raised 6 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Mary Josephine Hoare · Prevention of Future Deaths report
This summary was generated using AI from the published report. Please read the original report for the complete account.
Report summary
Mary Josephine Hoare died on 16 May 2019 at Queen Elizabeth Hospital from catastrophic injuries sustained after deliberately climbing over the balcony of her second-floor apartment and falling. The report raised concerns that she was accepted into unsuitable independent living accommodation without full information about her recent mental health history, adequate suitability assessment, care planning or risk assessments. It also remained a concern that other applicants might be accepted into supported living settings without being fully assessed.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Reliance on applicant and family information when assessing privately funded applicants
Wider context from the report “1. In April 2019, and currently, Friendship Care and Housing Limited (‘FCH’), who provide care at Phoenix House, and the Solihull Care Housing Association Limited (‘SCHA’), are reliant upon information from the applicant and their family when assessing the suitability of a privately funded applicant to become a resident .
” Source location Mary Josephine Hoare · Prevention of Future Deaths report
Open source report
8 Aug 2018 Dr Donald Clegg · Prevention of Future Deaths report Manchester North
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Concerns raised 2
Inadequate pre-admission assessment of care needs View source Inadequate pre-admission risk assessment View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
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AI-generated summary
Dr Donald Clegg · 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
Dr Donald Clegg, who had complex physical and mental health needs, was transferred to a short-term residential placement that was unable to manage his care needs. Concerns included inadequate assessment and communication during the transfer, unsafe medication management, insufficient monitoring, delayed recognition of deterioration and inadequate record keeping. He developed breathing difficulties and seizure-like activity on 26 February 2018, was admitted to hospital and died later that day; the stated cause of death was acute left ventricular heart failure due to severe ischaemic heart disease and left ventricular hypertrophy.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inadequate pre-admission assessment of care needs
Wider context from the report “Persona Only:
2. The process of assessment of care needs prior to admission was inadequate . Assessment is critical in establishing the suitability and safety of a placement – in this case, capable of meeting complex physical and mental health needs of the individual. Assessment of risk, in particular, was inadequate.
” Source location Dr Donald Clegg · 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 Inadequate pre-admission risk assessment
Wider context from the report “Persona Only:
2. The process of assessment of care needs prior to admission was inadequate. Assessment is critical in establishing the suitability and safety of a placement – in this case, capable of meeting complex physical and mental health needs of the individual. Assessment of risk, in particular, was inadequate .
” Source location Dr Donald Clegg · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Invite Elmhurst and Spurr House staff to Killelea discharge planning meetings to meet customers and assess suitability.
Verbatim wording from the response “Following a review of the discharge process from Killelea we have made the following change:” Source location 2018-0269-Response-by-Bury-Council
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Establish an additional short-stay admissions post to obtain detailed referral information and support face-to-face assessments or multidisciplinary meetings.
Verbatim wording from the response “In light of the findings from this inquest we have reviewed the assessment process and we will be enhancing our approach to admissions. This involves the establishment of an additional post within our short stay services which will focus on admissions, ensuring that we obtain detailed information for the Registered Manager to allow them to make an informed judgement. This will also provide capacity for a face to face assessment or involvement in multi-disciplinary team meetings (as described at point 1) as required.” Source location 2018-0269-Response-by-Persona
Open published response
14 May 2018 Gladys Kathleen Rich · Prevention of Future Deaths report Northamptonshire
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Concerns raised 1
Failure to identify falls risks during pre-assessment View source
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements No respondent-stated action or position is linked to these concerns in the published data.
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AI-generated summary
Gladys Kathleen Rich · 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
Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Failure to identify falls risks during pre-assessment
Wider context from the report “a) Failure to identify Mrs Rich as a falls risk during a pre-assessment process , despite the fact that she had sustained a fall requiring hospitalisation 9 months before. The pre-assessment check may not therefore be sufficiently robust .
” Source location Gladys Kathleen Rich · Prevention of Future Deaths report
Open source report
Concerns raised 1
Inconsistent application of controls preventing service commencement without a care plan and needs assessment 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. 1
The Haven Day Centre
Require all relevant documentation before accepting new placements.
View source
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AI-generated summary
Stanley Langdon · 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
Stanley Langdon died at Dipton Manor Care Home on 21 May 2017 from complications arising from a periprosthetic left femoral fracture sustained while carers assisted him to climb onto a minibus. The report states that he would not have sustained the fracture if he had been transferred in a wheelchair using the available hydraulic lift. The principal concerns were that services began without an adequate care plan or needs assessment, and that care planning was not based on complete information or agreed with his family, creating a risk of similar accidents and deaths in future.
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× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation Inconsistent application of controls preventing service commencement without a care plan and needs assessment
Wider context from the report “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user.
(5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently , and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users .
(6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day)
(7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council , and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day).
” Source location Stanley Langdon · Prevention of Future Deaths report
Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require all relevant documentation before accepting new placements.
Verbatim wording from the response “A report was received, and ALL suggested improvements were made as the documents attached confirm ref SCAN20170623, this was in place prior to the inquest date.” Source location 2018-0110-Response-by-Haven-Day-Centre
Open published response
Actions and positions describe what organisations say in published responses. Implementation is not independently verified.