Recipient

Abbotsbury Residential Home

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First report 29 Aug 2017•Latest report 29 Aug 2017

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Abbotsbury Residential Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Bedfordshire and Luton

    AI-generated summary

    BERYL MARGARET ELIZABETH GOODE · 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

    Beryl Margaret Elizabeth Goode fell while trying to use a commode, later became confused, and was subsequently found on the floor with an obvious head injury. She was taken to hospital and died on 2 May 2017. The principal concerns were that staff did not consider head injury as a possible cause of her confusion and lacked training to identify or exclude it, including when a resident denied injury.

    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 Abbotsbury Residential Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of night shift staff to consider and exclude possible head injury in residents with confusion

    Wider context from the report

    “(1) At no point did the night shift staff consider that a head injury could have been the cause of the deceased’s confusion. (2) It is accepted that the night shift are not medically trained. However, that makes it all the more important that they are aware of the possibility of a head injury to the residents, even in circumstances where the resident denies an injury. (3) It is also accepted that the deceased may not actually have had a head injury from the first fall. Nevertheless, without training, the staff were not able to exclude a head injury. (4) It is also accepted that calling the emergency services some 2 hours earlier would not have prevented her death if she had sustained a head injury in the first fall. However, in certain scenarios, residents in the future may have their lives saved if head injury is considered as a possible diagnosis. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026