25 Oct 2024 Sylvia Prichard · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 6 Failure to provide falls minimisation plans for residents at risk of falls View source Failure to provide wearable emergency alert devices to residents not assessed as high risk of falls View source Failure of oversight and auditing to identify non-implementation of the call bell response time policy View source Delays in responding to call bells View source Care plans containing out-of-date and conflicting information View source Failure of oversight and auditing to identify non-completion of falls minimisation plans View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 18
Action
Conduct Quality Team compliance inspections to oversee audit findings and ensure actions are completed promptly.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Complete falls risk assessments and multifactorial assessments and minimisation plans for residents identified as at risk.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Review call-bell technology, provide appropriate equipment access, and deploy care managers during busy periods to reduce response times.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Relaunch the updated call-bell policy and communicate the required two-to-five-minute response time to staff.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Issue a significant-learning briefing on call-bell response times and policy adherence.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Train key staff in care planning, record-keeping and falls management, with refresher training scheduled for record accuracy, falls management and risk recognition.
Stated in progressThe respondent said that this action was in progress when they made their response on 31 October 2024. View source
Action
Introduce an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Complete a full audit of residents’ care plans for accuracy, currency and consistency.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Review peak-hour staffing and optimise staff allocation to improve call-bell response efficiency.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Train the General Manager in the organisation’s falls-minimisation protocols and policies.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Disseminate updated falls-prevention policies and multifactorial falls-risk screening tools to managers for team implementation.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Cascade further falls-risk training to strengthen staff knowledge and risk-management documentation.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Implement daily call-bell response reporting and management oversight, with delayed responses investigated and staff performance addressed.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Embed revised call-bell procedures in staff briefings and induction training.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Introduce and operate a care-plan tracker with daily management checks and monthly care-record audits.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Reconfigure the call-bell system to escalate unanswered calls after three minutes to an emergency tone.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source
Action
Operate the Resident of the Day programme to review care plans with keyworkers and respond to current risks.
Stated completedThe respondent said that this action was complete when they made their response on 31 October 2024. View source See 15 more actions
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AI-generated summary
Sylvia Prichard · 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
Sylvia Prichard, a resident of Moorlands Lodge Care Home, had an unwitnessed fall on 28 March 2024 after a delayed response to her call bell and later died in hospital from a traumatic acute subdural haemorrhage. The concerns included the absence of a falls minimisation plan, outdated and conflicting care-plan information, persistent delays in responding to call bells, and inadequate oversight and auditing of these issues.
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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide falls minimisation plans for residents at risk of falls
Wider context from the report “- Mrs Prichard did not have a falls minimisation plan in place and the Manager of the care home was not aware that Avery Healthcare had a falls minimisation plan document which needed to be completed for residents at risk of falls. The Coroner is therefore concerned that other residents who are at risk of falls do not have falls minimisation plans in 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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure to provide wearable emergency alert devices to residents not assessed as high risk of falls
Wider context from the report “- Since Mrs Prichard’s death Moorlands Lodge Care Home has introduced watches which can be worn on the wrist and used to attract immediate attention in the event of a fall or other medical emergency. However, the watches have only been provided to residents who have been assessed as high risk of falls , meaning that others who have a fall, or another type of medical emergency, are still reliant on the pendant call button to gain assistance .
” 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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure of oversight and auditing to identify non-implementation of the call bell response time policy
Wider context from the report “- The Coroner is concerned that Avery Healthcare’s oversight and auditing measures failed to identify that the call bell response time policy was not being implemented at Moorlands Lodge Care Home for many months and further failed to identify that falls minimisation plans were not being completed for residents.
” 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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Delays in responding to call bells
Wider context from the report “- Audits show that, despite efforts to improve call bell response times, a significant number of call bells are still not responded to within two to five minutes . This is of concern as residents who are unable to move due to a medical emergency or fall are not able to use the emergency buttons on the wall.
” 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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Care plans containing out-of-date and conflicting information
Wider context from the report “- Mrs Prichard’s mobility care plan contained out of date and conflicting information. The Coroner is concerned that other residents’ care plans may contain out of date and conflicting information.
” 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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure of oversight and auditing to identify non-completion of falls minimisation plans
Wider context from the report “- The Coroner is concerned that Avery Healthcare’s oversight and auditing measures failed to identify that the call bell response time policy was not being implemented at Moorlands Lodge Care Home for many months and further failed to identify that falls minimisation plans were not being completed for residents .
” 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 Conduct Quality Team compliance inspections to oversee audit findings and ensure actions are completed promptly.
Verbatim wording from the response “• Internal Compliance Inspections are conducted by the Quality Team, which oversee all audit findings and ensure that actions are completed promptly and consider whether they may prompt an inspection on emerging risks.” Source location Response from Avery Healthcare Group
Open published response
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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 Complete falls risk assessments and multifactorial assessments and minimisation plans for residents identified as at risk.
Verbatim wording from the response “• All residents have a falls risk assessment completed on admission. For those residents identified as having an increased risk of falls, a further multifactorial falls risk assessment is indicated and completed on the electronic care planning system.” Source location Response from Avery Healthcare Group
Open published response
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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 Review call-bell technology, provide appropriate equipment access, and deploy care managers during busy periods to reduce response times.
Verbatim wording from the response “• A technology review within the Home has been undertaken to ensure all staff have access to the correct equipment ensuring they are all notified of calls. During the busy times of the day care managers support the team on the floor to ensure minimisation of response times.” Source location Response from Avery Healthcare Group
Open published response
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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 Relaunch the updated call-bell policy and communicate the required two-to-five-minute response time to staff.
Verbatim wording from the response “• The updated call bell response policy has been relaunched, and all staff are now fully aware of the expected 2–5-minute response time.” Source location Response from Avery Healthcare Group
Open published response
×
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 Issue a significant-learning briefing on call-bell response times and policy adherence.
Verbatim wording from the response “• In May, the Home issued a Significant Learning briefing regarding call bell response times and adherence to the policy.” Source location Response from Avery Healthcare Group
Open published response
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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 Train key staff in care planning, record-keeping and falls management, with refresher training scheduled for record accuracy, falls management and risk recognition.
Verbatim wording from the response “• All key staff have undergone additional training on care planning and record-keeping, with 100% compliance achieved for falls-related training. Refresher training is scheduled to address record accuracy, falls management, and risk recognition.” Source location Response from Avery Healthcare Group
Open published response
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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 Introduce an internal audit framework covering call-bell response times and falls-minimisation plans, with results shared with staff.
Verbatim wording from the response “• A new internal audit framework has been introduced, focusing on critical areas such as call bell response times and falls minimisation plans. All audit results will be shared transparently with staff to foster accountability.” Source location Response from Avery Healthcare Group
Open published response
×
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 Complete a full audit of residents’ care plans for accuracy, currency and consistency.
Verbatim wording from the response “• A full audit of all residents’ care plans has been completed by the Regional Quality Team to ensure they are accurate, up-to-date, and consistent.” Source location Response from Avery Healthcare Group
Open published response
×
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 Review peak-hour staffing and optimise staff allocation to improve call-bell response efficiency.
Verbatim wording from the response “• Staffing levels during peak hours have been reviewed to ensure they align with residents’ care needs.” Source location Response from Avery Healthcare Group
Open published response
×
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 Train the General Manager in the organisation’s falls-minimisation protocols and policies.
Verbatim wording from the response “• The new General Manager has been trained in Avery Healthcare’s falls minimisation protocols and policies to ensure proper implementation, consistency and to continue to drive improvements.” Source location Response from Avery Healthcare Group
Open published response
×
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 Disseminate updated falls-prevention policies and multifactorial falls-risk screening tools to managers for team implementation.
Verbatim wording from the response “• The Falls Prevention Policy and Multi-Factorial Falls Risk Screening Tool was sent to all Home Managers and General Managers to read and familiarise themselves with the changes and to update their staff and teams.” Source location Response from Avery Healthcare Group
Open published response
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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 Cascade further falls-risk training to strengthen staff knowledge and risk-management documentation.
Verbatim wording from the response “• Further Falls risk training has been cascaded to specifically coach staff and develop their knowledge, understanding and reasoning in respect of their completion of entries in the care plans with a higher emphasis of the risk management to be embedded within all the care documentation.” Source location Response from Avery Healthcare Group
Open published response
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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 Implement daily call-bell response reporting and management oversight, with delayed responses investigated and staff performance addressed.
Verbatim wording from the response “• Managers now receive daily log reports on call bell response times, allowing immediate intervention for delays and further investigation for non-compliance. The call bell logs are reviewed by the Home Manager on a daily basis and shared with the senior Operations Team for further oversight.” Source location Response from Avery Healthcare Group
Open published response
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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 Hold weekly clinical-risk meetings to analyse incidents, review risks and care plans, and assign actions with ownership and timescales.
Verbatim wording from the response “• Weekly Clinical Risk meetings are held within the Home, chaired by the General Manager and/or Deputy manager to analyse falls, accident and incidents, infections, admission, weight loss and medication reviews. Actions are agreed with timescales and ownership.” Source location Response from Avery Healthcare Group
Open published response
×
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 Embed revised call-bell procedures in staff briefings and induction training.
Verbatim wording from the response “• Staff have been fully briefed in the change in policy and the changes have been embedded into the induction training on the use of call bells.” Source location Response from Avery Healthcare Group
Open published response
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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 Introduce and operate a care-plan tracker with daily management checks and monthly care-record audits.
Verbatim wording from the response “• A Care Plan Tracker has been introduced. This is a live document which records all care plans required for each resident and the date they were last reviewed. This is checked daily by the Home Manager. The tracker is completed and reviewed in” Source location Response from Avery Healthcare Group
Open published response
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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 Reconfigure the call-bell system to escalate unanswered calls after three minutes to an emergency tone.
Verbatim wording from the response “• Furthermore, there has now been a full review and reconfiguration of the call bell system. This work will ensure that any call bell activated from any source, i.e. pendant or call point will ring for 3 minutes on the ordinary tone. If the call bell is not answered within 3 minutes, the call bell will be automatically escalated and change to an emergency call bell which has a different tone. The team are aware that emergency bells must be answered immediately, and this response is a whole home approach. This new system has made the use of the wrist-worn emergency watches unnecessary.” Source location Response from Avery Healthcare Group
Open published response
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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 Operate the Resident of the Day programme to review care plans with keyworkers and respond to current risks.
Verbatim wording from the response “• A “Resident of the Day” programme is fully operational within the Home, involving a comprehensive review of a resident’s care plan with their keyworker to ensure it” Source location Response from Avery Healthcare Group
Open published response
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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 The reconfigured call bell system makes wrist-worn emergency watches unnecessary for high-risk residents.
Verbatim wording from the response “• As of November 2024, wrist-worn emergency watches for high-risk residents have been discontinued.” Source location Response from Avery Healthcare Group
Open published response
Concerns raised 3 Failure to complete risk assessments within 24 hours of admission View source Failure of care staff to notice missing risk assessments when assessing patients’ daily needs and requirements View source Inadequate auditing of assessment completion View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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
Catherine Jux · 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
Catherine Jux died aged 86 on 5 April 2021 while being transported to hospital by ambulance after choking on food at Elvy Court Nursing Home. The substantive concerns were that a risk assessment was not completed within 24 hours of admission, staff did not identify this omission, and the home lacked an adequate auditing process for completed assessments.
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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure to complete risk assessments within 24 hours of admission
Wider context from the report “Evidence was given by Nursing Home manager and Nursing staff at the Elvy Court Nursing Home that:
(1) Due to an oversight by the home a risk assessment was not completed within 24 hours of the patient being admitted to the home.
(2) None of the Care Home staff who attended to the patient and who would refer to this risk assessment to assess a patient’s daily needs and requirements noticed the oversight in respect of this.
(3) There is not an adequate process in place for auditing that assessments have been completed particularly given the homes policy that they are completed within 24 hours of admission.
” 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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Failure of care staff to notice missing risk assessments when assessing patients’ daily needs and requirements
Wider context from the report “Evidence was given by Nursing Home manager and Nursing staff at the Elvy Court Nursing Home that:
(1) Due to an oversight by the home a risk assessment was not completed within 24 hours of the patient being admitted to the home.
(2) None of the Care Home staff who attended to the patient and who would refer to this risk assessment to assess a patient’s daily needs and requirements noticed the oversight in respect of this.
(3) There is not an adequate process in place for auditing that assessments have been completed particularly given the homes policy that they are completed within 24 hours of admission.
” 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 Avery Healthcare Group; that does not assign responsibility.
PFD Monitor interpretation Inadequate auditing of assessment completion
Wider context from the report “Evidence was given by Nursing Home manager and Nursing staff at the Elvy Court Nursing Home that:
(1) Due to an oversight by the home a risk assessment was not completed within 24 hours of the patient being admitted to the home.
(2) None of the Care Home staff who attended to the patient and who would refer to this risk assessment to assess a patient’s daily needs and requirements noticed the oversight in respect of this.
(3) There is not an adequate process in place for auditing that assessments have been completed particularly given the homes policy that they are completed within 24 hours of admission.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations