Recipient

Associate Director of Consumer Relations and Legal Affairs

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First report 3 Oct 2013•Latest report 3 Oct 2013

Recipient record

Reports, concerns and published responses

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 Associate Director of Consumer Relations and Legal Affairs linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. East London

    AI-generated summary

    Douglas Grey · 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

    Douglas Grey, a resident of a residential home, suffered two falls after an inflatable mattress was placed on top of his original mattress and later became unconscious. He died in hospital in the early hours of 5 May 2012; the medical cause of death was recorded as right-sided pneumonia due to an acute subdural haematoma. Concerns included the absence of a clear procedure for notifying district nurses, correctly installing equipment and reviewing its performance, and staff not recognising or reporting faults with the mattress in line with the home's policy.

    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 Associate Director of Consumer Relations and Legal Affairs; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a written procedure or policy for notifying district nurses of delivery of assessed equipment

    Wider context from the report

    “1. Evidence was given at the inquest that there was no clear written procedure or policy in place to ensure notification to the district nurses of delivery of equipment they had assessed as being needed, correct installation of that equipment and review of the equipment’s performance. ”
    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 Associate Director of Consumer Relations and Legal Affairs; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of carers to recognise and report faults in equipment delivered for residents

    Wider context from the report

    “2. Evidence was given at the inquest that despite a clear written policy on recognising and reporting faults in equipment delivered for residents, carers did not appear to recognise the faulty nature of the inflatable mattress and act in accordance with the written policy of the home. ”
    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 Associate Director of Consumer Relations and Legal Affairs; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a written procedure or policy for correct installation of assessed equipment

    Wider context from the report

    “1. Evidence was given at the inquest that there was no clear written procedure or policy in place to ensure notification to the district nurses of delivery of equipment they had assessed as being needed, correct installation of that equipment and review of the equipment’s performance. ”
    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 Associate Director of Consumer Relations and Legal Affairs; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a written procedure or policy for reviewing equipment performance

    Wider context from the report

    “1. Evidence was given at the inquest that there was no clear written procedure or policy in place to ensure notification to the district nurses of delivery of equipment they had assessed as being needed, correct installation of that equipment and review of the equipment’s performance. ”
    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