Recurring concern

Unreliable plaster-cast care and management

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First reported 10 Aug 2015•Latest report 12 Dec 2017

Definition

What this concern includes

Includes failures of controls specifically dedicated to plaster-cast care and management, including staff competence and refresher training, patient assessment in the Plaster Room, protocols, monitoring, documentation, escalation and related follow-up where these affect the safety of patients with plaster casts.

Not included

Excludes generic staff training or competence deficiencies not specifically tied to plaster-cast care and management.
Excludes general patient assessment, treatment or documentation failures that do not concern patients with plaster casts or the Plaster Room process.
Excludes failures in orthopaedic care unrelated to plaster-cast assessment, management or associated safety controls.
Excludes equipment or staffing deficiencies unless they directly impair the plaster-cast care and management process.

Reports: 2
Individual concerns: 6
Date range: 2015–2017
Stated actions: 5

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.

East and North Hertfordshire Teaching NHS Trust1

NHS England1

St Giles1

University Hospitals Birmingham NHS Foundation Trust1

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.

12 Dec2017
Birmingham and Solihull
Concerns raised5
1. Failure to provide the nursing home with information about monitoring a high risk plaster cast
2. Lack of a care plan for management and monitoring of the plaster cast
3. Lack of further staff training on plaster casts
1. Failure to adequately check the plaster cast for signs of infection
2. Failure to document pus on the plaster cast
This report raised 7 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
  Include plaster-cast management literature in discharge document checklists sent to care homes.
  Stated by University Hospitals Birmingham NHS Foundation TrustStated planned
2. Action
  Implement a care-of-plaster-cast policy and procedure at Avery Healthcare Group.
  Stated by Avery Healthcare GroupStated completed
3. Action
  Implement a plaster-cast care plan at Avery Healthcare Group.
  Stated by Avery Healthcare GroupStated completed
1. Action
  Provide staff supervision and training on safe management of residents with plaster casts.
  Stated by Avery Healthcare GroupStated completed
AI-generated summary

Francis Robert Beech · 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

Francis Robert Beech had a conservatively treated right ankle fracture and was discharged to a nursing home, where monitoring and care planning for his plaster cast were not arranged. Infection signs were present by 1 July 2017 but were not investigated promptly, and he later developed a severely infected compound fracture and pressure sores before dying from bronchopneumonia contributed to by chronic obstructive pulmonary disease and the infected fracture site.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to provide the nursing home with information about monitoring a high risk plaster cast
Wider context from the report
“5. Failing to provide any information to the nursing home about the need to monitor the plaster cast and that it was high risk. ”
Source location
Francis Robert Beech · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a care plan for management and monitoring of the plaster cast
Wider context from the report
“1. Failing to have any care plan for the management and monitoring of his plaster cast. ”
Source location
Francis Robert Beech · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of further staff training on plaster casts
Wider context from the report
“4. There has been no further training for staff on plaster casts. The nursing home should review the training needs for staff on the care and management of plaster casts. ”
Source location
Francis Robert Beech · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to adequately check the plaster cast for signs of infection
Wider context from the report
“2. Failing to adequately check the plaster cast for signs of infection ”
Source location
Francis Robert Beech · Prevention of Future Deaths report
Page 2 · concerns
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Failure to document pus on the plaster cast
Wider context from the report
“6. Failing to document pus on the cast when he attended for a hip x-ray on 01/07/17. ”
Source location
Francis Robert Beech · 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
Include plaster-cast management literature in discharge document checklists sent to care homes.

Verbatim wording from the response
“In future, nursing staff will ensure that the literature on all plaster cast management is included within the checklist of documents to be sent to the home and not simply provided to the patient.”

Source location
2017-0367-Responses
Page 3 · response
Published 11 February 2018
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 care-of-plaster-cast policy and procedure at Avery Healthcare Group.

Verbatim wording from the response
“In response to your concerns I can confirm that we have implemented the following:”

Source location
2017-0367-Responses
Page 5 · response
Published 11 February 2018
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 plaster-cast care plan at Avery Healthcare Group.

Verbatim wording from the response
“In response to your concerns I can confirm that we have implemented the following:”

Source location
2017-0367-Responses
Page 5 · response
Published 11 February 2018
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
Provide staff supervision and training on safe management of residents with plaster casts.

Verbatim wording from the response
“In response to your concerns I can confirm that we have implemented the following:”

Source location
2017-0367-Responses
Page 5 · response
Published 11 February 2018
Open published response
10 Aug2015
Bedfordshire and Luton
Concerns raised1
1. Lack of a protocol for assessing patients attending the Plaster Room
This report raised 1 other concern. 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
  Issue interim guidance requiring plaster-room technicians and fracture-clinic staff to obtain medical review in specified circumstances.
  Stated by East and North Hertfordshire Teaching NHS TrustStated completed
AI-generated summary

LORRAINE JOYCE BIRD · 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

Lorraine Joyce Bird fractured her ankle after a fall and later attended a plaster room with numbness in her foot. The report identifies concerns that a developing deep vein thrombosis was not recognised or medically reviewed, that there was no adequate assessment protocol, and that she had not received low molecular weight heparin. The inquest concluded that this resulted in a lost opportunity for further treatment and that she died on 13 September 2014.

Read the report on judiciary.uk
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below.
PFD Monitor interpretation
Lack of a protocol for assessing patients attending the Plaster Room
Wider context from the report
“(2) There appears to be a complete lack of a Protocol for the assessment of patients who attend for treatment at the Plaster Room. ”
Source location
LORRAINE JOYCE BIRD · 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
Issue interim guidance requiring plaster-room technicians and fracture-clinic staff to obtain medical review in specified circumstances.

Verbatim wording from the response
“Prior to this incident there was no written guidance available to the Plaster room technicians. Current venous thromboembolic (VTE) guidance (incorporating NICE and Royal College of Emergency Medicine recommendations) is under review with full compliance with all recommendation currently anticipated for March 2016. Pending approval and ratification of this new overarching policy, the Clinical Director for Orthopaedics has issued immediate interim guidance to all plaster room technicians and fracture clinic medical staff.”

Source location
2015-0315-Response-by-East-North-Hertfordshire-NHS-Trust
Page 1 · response
Published 10 August 2015
Open published response

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised5

Failure to provide the nursing home with information about monitoring a high risk plaster cast

Lack of a care plan for management and monitoring of the plaster cast

Lack of further staff training on plaster casts

Failure to adequately check the plaster cast for signs of infection

Failure to document pus on the plaster cast

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.4

Concerns raised1

Lack of a protocol for assessing patients attending the Plaster Room

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

Actions described in response 4

Actions described in response 1