23 Dec 2021 Dilys Greta Etchells · Prevention of Future Deaths report West Yorkshire (Western)
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Concerns raised 16 Inadequate care plan protocols View source Inadequate note taking View source Inadequate protocols for initial wound assessment View source Insufficient staff training for visual checks at handover View source Inadequate protocols for return from hospital forms View source Failure of protocols to ensure compliance with care plans View source Inadequate provision of crash and sensor mats View source Inadequate documentation of crash and sensor mat use View source Insufficient staff training for communications at handover View source Inadequate documentation of visual checks on residents in their rooms View source Failure to appropriately deal with hospital correspondence concerning patient care View source Inadequate wound management protocols View source Inadequate protocols for completion of admission documentation View source Failure to report accidents when they take place View source Inadequate body map protocols View source Inadequate protocols for consent to medical treatment forms View source See 13 more concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Dilys Greta Etchells · 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
Dilys Greta Etchells was found after an unwitnessed fall at her nursing home, later diagnosed with fractures of the left tibia and fibula, and subsequently developed pressure ulcers before dying in hospital on 2 July 2021. The report identified concerns about the absence or documentation of fall-prevention measures, delayed medical referral, inadequate care documentation, handover communications, and wound-management procedures.
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate care plan protocols
Wider context from the report “• To review existing protocols governing wound management, completion of admission documentation, care plans , initial wound assessment, body maps, consent to medical treatment form and the return from hospital form.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate note taking
Wider context from the report “• To review existing practices with regard to the adequacy of note taking and to consider protocols to ensure compliance with care plans.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate protocols for initial wound assessment
Wider context from the report “• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment , body maps, consent to medical treatment form and the return from hospital form.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training for visual checks at handover
Wider context from the report “• To give consideration to staff training with respect to visual checks at handover to ensure resident’s needs are met in accord with the care plans.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate protocols for return from hospital forms
Wider context from the report “• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form .
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of protocols to ensure compliance with care plans
Wider context from the report “• To review existing practices with regard to the adequacy of note taking and to consider protocols to ensure compliance with care plans .
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate provision of crash and sensor mats
Wider context from the report “• To review and reconsider the adequacy of the provision of crash and sensor mats and the means for properly documenting their use and reporting accidents when they take place.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentation of crash and sensor mat use
Wider context from the report “• To review and reconsider the adequacy of the provision of crash and sensor mats and the means for properly documenting their use and reporting accidents when they take place.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training for communications at handover
Wider context from the report “• To consider the necessity of staff training with regard to communications at handover and dealing with correspondence received from the hospital with regard to patient care.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate documentation of visual checks on residents in their rooms
Wider context from the report “• Consider the adequacy of the supporting documentation with regard to visual checks on residents in their rooms .
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately deal with hospital correspondence concerning patient care
Wider context from the report “• To consider the necessity of staff training with regard to communications at handover and dealing with correspondence received from the hospital with regard to patient care .
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate wound management protocols
Wider context from the report “• To review existing protocols governing wound management , completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate protocols for completion of admission documentation
Wider context from the report “• To review existing protocols governing wound management, completion of admission documentation , care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to report accidents when they take place
Wider context from the report “• To review and reconsider the adequacy of the provision of crash and sensor mats and the means for properly documenting their use and reporting accidents when they take place .
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate body map protocols
Wider context from the report “• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps , consent to medical treatment form and the return from hospital form.
” 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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate protocols for consent to medical treatment forms
Wider context from the report “• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations