Recipient

Ambassador House

First report 16 Feb 2017•Latest report 16 Feb 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
Published responses: 100%
Concerns addressed: 5
Stated actions: 3

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.

100%published responses found

3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

16 Feb2017
Bedfordshire and Luton
Concerns raised5
1. Lack of sufficiently specific care plans for required assistance
2. Failure to provide guidance for undertaking risk assessments
3. Insufficient staffing capacity for assisting residents requiring two carers
1. Insufficient staffing capacity for best-interests decisions and hospital accompaniment
2. Failure to follow paramedics' recommendations
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
  Update care plans to require that residents using bedrails are not left unattended when rails are lowered for assistance.
  Stated planned
Respondent positions 3
1. Position
  Policies and procedures were followed; the incident resulted from a senior staff member’s negligence.
  Disputes the concern
1. Position
  Seeking specialist treatment rather than a GP was considered justified by the resident’s swollen, painful knee.
  Disputes the concern
2. Position
  Staffing levels complied with regulations and did not make hospital admission inappropriate.
  Disputes the concern
AI-generated summary

ETHELINE DE-GALE · 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

Etheline De-Gale fell while mobilising from bed at a care setting on the night of 7/8 March 2016. Hospital admission was declined, follow-up with a doctor did not occur as recommended, and an ambulance attended the following afternoon; she later underwent surgery, contracted bronchopneumonia and died from a pulmonary embolism on 16 March 2016. Concerns included an insufficiently clear care plan, inadequate guidance on risk assessments, limited staffing, and the apparent failure to follow paramedic recommendations.

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 Ambassador House; that does not assign responsibility.
PFD Monitor interpretation
Lack of sufficiently specific care plans for required assistance
Wider context from the report
“(1) The care plan was too vague to be of assistance to the carers. The carer understood that the deceased required 2 carers to assist her to the commode, but interpreted that as being limited to walking across the floor, but not sitting up in bed with the sides removed or sitting on the side of the bed. ”
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 Ambassador House; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide guidance for undertaking risk assessments
Wider context from the report
“(2) The Deputy Manager indicated that the carer should have undertaken a risk assessment, but could offer no guidance on how that was to be achieved. ”
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 Ambassador House; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing capacity for assisting residents requiring two carers
Wider context from the report
“(3) There were only 2 members of staff on duty, which compromised the safety of other residents when a resident required 2 members of staff to assist. ”
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 Ambassador House; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staffing capacity for best-interests decisions and hospital accompaniment
Wider context from the report
“(4) There were only 2 members of staff on duty, which potentially could compromise decisions made in the best interests of a resident. One carer accompanying a resident to hospital would clearly create a problem and that could potentially be seen as a basis for not admitting a resident to hospital. ”
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 Ambassador House; that does not assign responsibility.
PFD Monitor interpretation
Failure to follow paramedics' recommendations
Wider context from the report
“(5) The recommendation of the paramedics appears to have been ignored. ”
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
Update care plans to require that residents using bedrails are not left unattended when rails are lowered for assistance.

Verbatim wording from the response
“The care plan should stipulate that when bedrails are used for any resident and they are lowered for assistance to the resident, the resident must not be left unattended. This will be in place by 3rd March 2017.”

Source location
2017-0058-Response-Ambassador-House-Home
Page 3 · response
Published 6 March 2017
Open published response
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
Policies and procedures were followed; the incident resulted from a senior staff member’s negligence.

Verbatim wording from the response
“Based on the information from statements, staff interview, care plans, risk assessments and LR’s personnel file, we have concluded that in this case we have acted in accordance with our policies and procedures. The incident occurred, we believe, because of the negligence of a senior staff member (LR).”

Source location
2017-0058-Response-Ambassador-House-Home
Page 3 · response
Published 6 March 2017
Open published response
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
Seeking specialist treatment rather than a GP was considered justified by the resident’s swollen, painful knee.

Verbatim wording from the response
“The advice of the paramedics to call her GP was ignored on the basis that EDG’s right knee was swollen and painful and therefore the need for a GP to come to the home and instruct us to call an ambulance was negated. It was clear to the Deputy that more specialist treatment was required.”

Source location
2017-0058-Response-Ambassador-House-Home
Page 2 · response
Published 6 March 2017
Open published response
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
Staffing levels complied with regulations and did not make hospital admission inappropriate.

Verbatim wording from the response
“The numbers of staff on duty at the time of the incident were in line with regulation and are allocated based on need of our residents. At night time the residents are in bed and mostly sleep. There is a requirement of staff to regularly check those residents who require care and to attend residents when they call for assistance. It would be rare for two residents to call at the same time, however, should this be the case, a staff member would attend each resident independently, assess the need for the call, ensure the resident was safe and then prioritise the tasks with their colleague in order to assist the residents. The duty of the care staff attending a resident is to acknowledge the individual risk. In this case LR willingly left EDG on the side of the bed, without thought of her falling.”

Source location
2017-0058-Response-Ambassador-House-Home
Page 2 · response
Published 6 March 2017
Open published response

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

Reports, concerns and published responses

Reports over time

Concerns raised5

Lack of sufficiently specific care plans for required assistance

Failure to provide guidance for undertaking risk assessments

Insufficient staffing capacity for assisting residents requiring two carers

Insufficient staffing capacity for best-interests decisions and hospital accompaniment

Failure to follow paramedics' recommendations

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.1

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.3

Actions described in response 1

Respondent positions 3