Concerns raised 4 Inadequate assessment of patient mobility View source Failure of staff to operate stand aids safely View source Failure of staff to be aware of patients' mobility limitations View source Use of an unsafe stand aid for non-weight-bearing patients View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Annie Ceinwen Jones · 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
Annie Ceinwen Jones was admitted to hospital on 1 December 2012 after feeling very poorly and sustaining extensive bruising in a fall from a stand aid. The investigation identified inadequate mobility assessment, an unsafe stand aid, and gaps in staff awareness and competence, although the report states that the incident did not contribute to her death; the inquest conclusion was natural, with bronchopneumonia, volvulus of the sigmoid colon with infarction, and intestinal obstruction recorded as the medical cause of death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbey Dale House; that does not assign responsibility.
PFD Monitor interpretation Inadequate assessment of patient mobility
Wider context from the report “During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years.
1. An inadequate assessment of the mobility of Mrs Jones was made
2. The stand aid was unsafe for use with Mrs Jones
3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility
4. Not all staff were able to operate the stand safely.
Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbey Dale House; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to operate stand aids safely
Wider context from the report “During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years.
1. An inadequate assessment of the mobility of Mrs Jones was made
2. The stand aid was unsafe for use with Mrs Jones
3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility
4. Not all staff were able to operate the stand safely .
Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbey Dale House; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to be aware of patients' mobility limitations
Wider context from the report “During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years.
1. An inadequate assessment of the mobility of Mrs Jones was made
2. The stand aid was unsafe for use with Mrs Jones
3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility
4. Not all staff were able to operate the stand safely.
Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Abbey Dale House; that does not assign responsibility.
PFD Monitor interpretation Use of an unsafe stand aid for non-weight-bearing patients
Wider context from the report “During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing . Mrs Jones had not been weight bearing for over three years.
1. An inadequate assessment of the mobility of Mrs Jones was made
2. The stand aid was unsafe for use with Mrs Jones
3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility
4. Not all staff were able to operate the stand safely.
Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death.
” 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 Create an accessible resident mobility summary and person-handling plan for all care staff, including new and agency staff.
Verbatim wording from the response “In order to overcome any communication issues with regards to manual-handling changes, and to provide a point of reference for all staff (including new/agency staff), an updated document has been created to provide a snapshot of each resident's needs, which includes a summary person handling plan, which is readily available to all care staff.” Source location 2013-0306-Response-by-Abbey-Dale-House
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 Add staff and assessor sign-off sections documenting competence with each item of manual-handling equipment.
Verbatim wording from the response “The improved documentation will include sections for staff and assessor to sign off that they are competent using each piece of manual handling equipment.” Source location 2013-0306-Response-by-Abbey-Dale-House
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 Complete specialised train-the-trainer education covering manual handling and person-handling risk assessments.
Verbatim wording from the response “Following this event, and to improve the provision of manual handling training within Abbey Dale House, I undertook a 4-day specialised Train-the-trainer course in February 2012, run by Edge Services, a national company that specialise in Manual Handling Training. This course also involved a risk assessment element to the course, to enable full manual handling and person handling risk assessments to be performed by myself.” Source location 2013-0306-Response-by-Abbey-Dale-House
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve the completeness and legibility of mobility risk-assessment paperwork.
Verbatim wording from the response “We acknowledge that the paperwork accompanying the risk assessment was not as comprehensive or as legible as it could have been, and we have taken steps to overcome these issues.” Source location 2013-0306-Response-by-Abbey-Dale-House
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 Adopt the All-Wales Manual Handling Passport training programme, including person-handling modules.
Verbatim wording from the response “In order to improve this, Abbey Dale House has adopted the All-Wales Manual Handling Passport, which is an intensive manual-handling training programme and includes person handling modules.” Source location 2013-0306-Response-by-Abbey-Dale-House
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The stand-aid was not considered unsafe because it had been successfully used, formally reviewed monthly, and supported by staff assessments.
Verbatim wording from the response “Mrs Jones had successfully used this particular equipment since the original assessment in March 2012, and the manual handling plan was formally reviewed monthly. On each occasion that any resident is transferred with equipment, the staff have to assess their ability to follow instructions; and to also assess their physical capabilities, which can vary from day-to-day, and even from hour-to-hour.” Source location 2013-0306-Response-by-Abbey-Dale-House
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The resident was unable to walk but could partially weight-bear sufficiently to transfer using the stand-aid.
Verbatim wording from the response “In section 5, your report stated that Mrs Jones had not been weight-bearing for over three years. I believe that there has been some misunderstanding about this term. Mrs Jones had not been able to walk since she had been with us (since 23rd June 2010), but she was able to partially weight-bear - sufficiently to transfer with a stand-aid.” Source location 2013-0306-Response-by-Abbey-Dale-House
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations