Recipient

Beechwood Lodge

First report 19 Nov 2018•Latest report 19 Nov 2018

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: 5

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

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

19 Nov2018
Manchester North
Concerns raised5
1. Failure to refer people at high risk of falls to the falls prevention team
2. Failure to undertake falls prevention care plans
3. Failure to provide falls prevention equipment
1. Failure to undertake falls risk assessments
2. Failure to identify people at high risk of falls
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 4
1. Action
  Strengthen risk assessments for residents who have experienced falls.
  Stated completed
2. Action
  Implement a falls matrix to monitor falls and support referrals to the falls team when required.
  Stated completed
3. Action
  Add safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.
  Stated completed
1. Action
  Refer all falls-risk concerns to appropriate professionals, including doctors and falls teams.
  Stated completed
Respondent positions 1
1. Position
  Falls-prevention equipment was considered inappropriate because of trip hazards from extremely poor eyesight, with the existing call bell enabling assistance when required.
  Existing arrangements considered sufficient
AI-generated summary

Beryl Ann Walsh · 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

Beryl Ann Walsh sustained catastrophic head injuries in an unwitnessed fall from her bed at Beechwood Lodge Care Home on 3 June 2018, which led directly to her death. The principal concerns were missed opportunities to identify her as being at high risk of falls, refer her to the falls team, provide falls-prevention equipment, and undertake falls-risk assessments and care plans.

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 Beechwood Lodge; that does not assign responsibility.
PFD Monitor interpretation
Failure to refer people at high risk of falls to the falls prevention team
Wider context from the report
“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”
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 Beechwood Lodge; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake falls prevention care plans
Wider context from the report
“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”
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 Beechwood Lodge; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide falls prevention equipment
Wider context from the report
“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”
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 Beechwood Lodge; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake falls risk assessments
Wider context from the report
“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”
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 Beechwood Lodge; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify people at high risk of falls
Wider context from the report
“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”
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
Strengthen risk assessments for residents who have experienced falls.

Verbatim wording from the response
“1. We have put more in robust risk assessments for residents who have had falls.”

Source location
2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019
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
Implement a falls matrix to monitor falls and support referrals to the falls team when required.

Verbatim wording from the response
“3. We have now put all new risk assessments in all care plans about safety equipment whether they use it or why they do and the reasons why they don’t. I also have put in place a falls matrix, so I can monitor falls and do referrals to falls team when required.”

Source location
2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019
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
Add safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.

Verbatim wording from the response
“3. We have now put all new risk assessments in all care plans about safety equipment whether they use it or why they do and the reasons why they don’t. I also have put in place a falls matrix, so I can monitor falls and do referrals to falls team when required.”

Source location
2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019
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
Refer all falls-risk concerns to appropriate professionals, including doctors and falls teams.

Verbatim wording from the response
“4. We will ensure all falls risk concerns are referred to appropriate professionals i.e. doctors and falls teams.”

Source location
2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019
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
Falls-prevention equipment was considered inappropriate because of trip hazards from extremely poor eyesight, with the existing call bell enabling assistance when required.

Verbatim wording from the response
“The falls that BW sustained was over a 3 and half year period, the equipment what would be usually required was more of a risk to BW due to extremely poor eyesight so equipment for falls prevention was not appropriate due to trip hazards, however BW had good capacity so was able to use the call bell she had in place when she required assistance.”

Source location
2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019
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

Failure to refer people at high risk of falls to the falls prevention team

Failure to undertake falls prevention care plans

Failure to provide falls prevention equipment

Failure to undertake falls risk assessments

Failure to identify people at high risk of falls

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.4

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 4

Respondent positions 1