19 Nov 2018 Beryl Ann Walsh · Prevention of Future Deaths report Manchester North
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Concerns raised 5 Failure to refer people at high risk of falls to the falls prevention team View source Failure to undertake falls prevention care plans View source Failure to provide falls prevention equipment View source Failure to undertake falls risk assessments View source Failure to identify people at high risk of falls View source See 2 more concerns
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
Action
Strengthen risk assessments for residents who have experienced falls.
View source
Action
Implement a falls matrix to monitor falls and support referrals to the falls team when required.
View source
Action
Add safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.
View source
Action
Refer all falls-risk concerns to appropriate professionals, including doctors and falls teams.
View source See 1 more action
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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.
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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 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
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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 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
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 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
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 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
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
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 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations