14 May 2018 Gladys Kathleen Rich · Prevention of Future Deaths report Northamptonshire
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Concerns raised 8 Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input View source Failure of the Falls Prevention Service to proactively follow up required input View source Failure to transmit and resubmit completed falls action plans through the required process View source Failure to use appropriate falls referral thresholds View source Unavailability of required falls prevention equipment View source Failure to consider and action falls risk action plan advice View source Failure to make new falls prevention referrals after further falls View source Failure to identify falls risks during pre-assessment View source See 5 more concerns
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AI-generated summary
Gladys Kathleen Rich · 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
Gladys Kathleen Rich suffered repeated falls after moving into Avenue House Nursing and Care Home, culminating in a fall on 28 December 2016 that caused traumatic subdural and subarachnoid haemorrhages and a skull fracture. She died on 3 March 2017; the medical cause of death included chest infection, intracranial haemorrhage and a fall, with rectal cancer and liver metastases also recorded. The principal concerns related to failures to identify and manage her falls risk, ineffective referral and follow-up by the care home and Falls Prevention Service, inadequate resources and equipment, and the absence of an effective system to ensure required falls-prevention input was delivered.
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× 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 Avenue House Nursing and Care Home; that does not assign responsibility.
PFD Monitor interpretation Lack of a mechanism to ensure safe delivery and discharge of Falls Prevention Service input
Wider context from the report “3. There does not seem to be any mechanism for ensuring that Falls Prevention Service input is in fact delivered when it is required and that a patient is only ever discharged or that it is clear that the underlying symptoms causing the falls are resolved or that measures have been put in place to mitigate the falls risk .
” 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 Avenue House Nursing and Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of the Falls Prevention Service to proactively follow up required input
Wider context from the report “2. In relation to the Falls Prevention Service.
a) Despite Mrs Rich having been referred to the Falls Prevention Service by her GP and the service being notified of a fall related hospitalisation in August 2016, the onus was placed on the patient and her family to make a further appointment . In the absence of any further contact, the service assumes that their input is no longer required . As is clear in the case of Mrs Rich, the prevention service was very much still required. Again, when the service was contacted in November 2016 the failure to receive a form or a response to the subsequent letter again led to an automatic assumption that input was no longer required despite the fact that this was the second referral to have been made in relation to Mrs Rich. It was explained in evidence that the reason the service cannot be more proactive is because they are inadequately resourced .
” 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 Avenue House Nursing and Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to transmit and resubmit completed falls action plans through the required process
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile . Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted . Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service.
” 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 Avenue House Nursing and Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to use appropriate falls referral thresholds
Wider context from the report “b) The policy of waiting for 3 falls before making a referral seems to be arbitrary and also at odds with the Fall Prevention Service requirement of 1 fall within a 12 month period before a referral will be accepted .
” 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 Avenue House Nursing and Care Home; that does not assign responsibility.
PFD Monitor interpretation Unavailability of required falls prevention equipment
Wider context from the report “d) The care home may not have some of the equipment that they require for patients such as Mrs Rich e.g. a bed sensor mat .
” 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 Avenue House Nursing and Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to consider and action falls risk action plan advice
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned . Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service.
” 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 Avenue House Nursing and Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to make new falls prevention referrals after further falls
Wider context from the report “c) Once a referral was made, and a falls risk action plan was received the advice within does not appear to have been properly considered or actioned. Furthermore, the action plan was returned to the Falls Prevention Service by post rather than the required method of facsimile. Although the care home was notified that the Falls Prevention Service had not received the completed action plan, it was not resubmitted. Despite Mrs Rich then suffering a series of further falls, no new referrals were made to the Falls Prevention Service .
” 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 Avenue House Nursing and Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to identify falls risks during pre-assessment
Wider context from the report “a) Failure to identify Mrs Rich as a falls risk during a pre-assessment process , despite the fact that she had sustained a fall requiring hospitalisation 9 months before. The pre-assessment check may not therefore be sufficiently robust .
” 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 Contact the Falls Team after sending referrals and action plans, confirm receipt and intended action, and record each contact in residents’ care plans.
Verbatim wording from the response “Although we believe we followed normal and reasonable procedures in this case, in future to further mitigate against shortcomings of the Falls Team, we will contact them after sending them referrals and action plans. This will be done to ensure that the Falls Team have received them and to find out what action they intend to take. All contact will be recorded in our residents’ Care plans under the visiting professionals’ information section.” Source location 2018-0149_Redacted-Response-by-Avenue-House-Care-Home
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How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The company’s policy requiring referral after three known falls is considered reasonable and sufficient.
Verbatim wording from the response “B) The management of the home followed the company’s policy about making a referral after three falls (that it was aware of). We believe the company’s policy is reasonable and is common across the care home industry. However, if the home had been informed of Mrs Rich’s previous falls, and her previous referrals to the falls team, the home would have referred Mrs Rich sooner under this reasonable and balanced policy. The Coroner should also note that the home has recently referred residents, who have had 3 or 4 falls to the Falls Team, and even after this number of falls, the Falls Team have made the decision not to get involved in the management of these residents’ falls.” Source location 2018-0149_Redacted-Response-by-Avenue-House-Care-Home
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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 Floor-based sensor mats and staff monitoring are considered sufficient; bed sensors offer no additional advantage and communal-area sensors are unsafe.
Verbatim wording from the response “out of bed, she did have a sensor mat on the floor by her bed, which did alert staff if she was up and walking around her bedroom. A floor based sensor mat is the normal equipment used in care homes for residents at risk of falls. Bed sensor mats are extremely rare and we believe do not offer any advantages over floor based pressure mats. Mrs Rich also had falls in the communal areas of the home and unfortunately no sensor could safely be used to reduce the likelihood of these. However, staff were aware of her high falls risk, and did monitor her when mobilising independently with her frame.” Source location 2018-0149_Redacted-Response-by-Avenue-House-Care-Home
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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 After submitting referrals and action plans, the care home must wait for the Falls Team’s input and decisions.
Verbatim wording from the response “C) The management of the home completed the falls risk assessment and action plan and sent this by post, and not by the fax facility. There was a copy of this in the resident’s file for reference. There was no information in the resident’s file to say that the falls team hadn’t received this information. Mrs Rich had also been referred to the Falls Team prior to admission to Avenue House and again this was not followed up by the Falls Team. Once falls risk action plans are received by the falls team, they do not typically give the home even a rough estimate of how long it will be before it is followed up and the resident is seen. Therefore the care home simply has to wait for the Falls’ Team’s input.” Source location 2018-0149_Redacted-Response-by-Avenue-House-Care-Home
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations