9 Aug 2020 Peter William Howarth · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Lack of investigations into falls in care and nursing homes View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter William Howarth · 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
Peter William Howarth, who had complex underlying health problems, died in hospital after sustaining injuries in a number of falls, including a fractured neck of femur requiring surgery. The report raised concern that Borough Care had not investigated the fall at the care home that led to his final hospital admission.
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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of investigations into falls in care and nursing homes
Wider context from the report “1. The court heard evidence that, despite the fact Mr Howarth was injured in a fall at his care home which led to his final admission to hospital, Borough Care has not undertaken any investigation into the circumstances of that fall . Robust investigations into falls in care and nursing homes are essential with a view to considering whether or not there is any learning to be derived from the incident for the benefit of other residents with a view to reducing the risk of death arising from falls in similar circumstances.
” 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 Complete weekly falls analyses and record actions taken.
Verbatim wording from the response “Managers must now complete a weekly falls analysis and detail all actions taken. If a resident has more than 2 falls in any period of 2 weeks a referral must be made to their GP or to the falls clinic.” Source location 2020-0171-Response-from-Borough-Care_Redacted.pdf
Open published response
Concerns raised 6 Failure to review and reassess falls risk after sequential falls View source Lack of an escalation pathway following sequential falls View source Failure to conduct internal investigations into falls View source Lack of an adequate falls assessment policy View source Failure to complete and update falls-related records View source Failure to proactively implement measures to reduce escalating falls risk View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Andrew Richard Hogg · 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
Andrew Richard Hogg, who had Parkinson’s disease and possible dementia, died on 6 May 2019 after a fall at Meadway Court Care Home caused a head injury and subdural haematoma. The principal concerns were the absence of adequate falls assessment, escalation, investigation and proactive measures to reduce the risk after his repeated falls.
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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to review and reassess falls risk after sequential falls
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019 . There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of an escalation pathway following sequential falls
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct internal investigations into falls
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of an adequate falls assessment policy
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and update falls-related records
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk.
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record .
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision.
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to proactively implement measures to reduce escalating falls risk
Wider context from the report “I heard evidence of the sequence of falls which I have recounted above. While there may have been a falls assessment when Andrew first became resident at the home, there was no evidence before me of the nature and extent of that assessment. More particularly there was no evidence of any steps taken to review or reassess the falls risk following the falls Andrew had commencing in January 2019. There were some 7 falls before his final fall and it is a matter of concern that while each seems to have been dealt with reactively in that relevant assistance was sought, there were no steps considered to address what clearly was an escalating risk .
In evidence I heard from ████████ who was the manager of the home (although I accept he was only recently in post). ████████ having given evidence as to the facts above accepted that insufficient measures were taken to address the risks which were evident. In particular he identified that:-
1. Not all the relevant paperwork was completed following the falls
2. There could have been engagement with other services such as the local falls clinic
3. Consideration should have been given to using available equipment such as a sensor mat and “silent minder”
4. Relevant information should have been updated onto the patient’s electronic record.
While I welcome his insightful comments I remain concerned that
1. There was no adequate falls assessment policy
2. There was no obvious escalation pathway following the sequential falls Andrew had
3. There was no internal investigation into any of the falls which occurred
4. There was no consideration of steps which could have been taken to reduce the risk, whether by way of equipment or increased or more direct care supervision .
It seems to me that each incident was dealt with reactively and individually with no proactive consideration given steps which could be taken to reduce or ameliorate the risk of falling which quite obviously was increasing.
While it cannot be said that had such steps been taken Andrew would not have fallen when he did, I do think that the risk of that happening would have been substantially reduced.
” 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 Arrange a GP or CPN review for any resident experiencing more than two falls within two weeks.
Verbatim wording from the response “However, to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. Managers will print the falls log for the week and add notes as to what actions have been taken. These notes will also be added to the support plans of those residents involved. Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
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 falls weekly in the PCS system, document actions, and update affected residents’ support plans.
Verbatim wording from the response “However, to tighten up our process all home managers will be reviewing falls on our PCS (Person Centered Software) system on a weekly basis to ensure that falls are monitored more frequently. Managers will print the falls log for the week and add notes as to what actions have been taken. These notes will also be added to the support plans of those residents involved. Collectively as a group of managers we have also agreed that any resident who has more than two falls within a two week period we will arrange a review with their GP or CPN.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
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 Audit the falls-review process monthly through Area Managers’ audits.
Verbatim wording from the response “This process will be reviewed by our Area Managers as part of their monthly audit.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
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 Each individual fall was dealt with appropriately, although the overall number and timing of falls were not reviewed at that time.
Verbatim wording from the response “I have investigated your concerns and I agree that each fall had been dealt with appropriately, but a review into the number of falls and the timescale in which the falls occurred did not appear to happen at that time.” Source location 2019-0400-Response-from-Borough-Care-Ltd-Redacted
Open published response
14 Nov 2017 Kathleen Smith · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 3 Failure to audit or review incidents and issues after the departure of the responsible manager View source Failure to notify the corporate risk function of incident circumstances View source Internal incident reporting and escalation process depending largely on an individual manager View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Kathleen Smith · 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
Kathleen Smith, who had Alzheimer’s dementia, sustained a hip fracture at her care home on 12 April 2017 after being pushed to the floor by another resident. She underwent surgery, was discharged back to the care home for palliation, and subsequently died. Concerns raised at the inquest included failures to notify her family and the organisation’s corporate risk function, and the lack of audit or review of incidents after the departure of a manager responsible for reporting and escalation.
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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to audit or review incidents and issues after the departure of the responsible manager
Wider context from the report “In the course of the inquest I heard evidence that, whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained injury on 12th April 2017, neither the family nor Borough Care’s corporate risk function had been notified of the circumstances which led to Mrs Smith’s hip fracture. This latter point raises a particular concern as to Borough Care’s ability to undertake any meaningful investigation into the circumstances of Mrs Smith’s injury, with a view to deriving learning for the benefit of other residents.
The inquest also heard evidence that Lisburne Court’s process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care’s employment. It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question , despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing.
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to notify the corporate risk function of incident circumstances
Wider context from the report “In the course of the inquest I heard evidence that, whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained injury on 12th April 2017, neither the family nor Borough Care’s corporate risk function had been notified of the circumstances which led to Mrs Smith’s hip fracture . This latter point raises a particular concern as to Borough Care’s ability to undertake any meaningful investigation into the circumstances of Mrs Smith’s injury, with a view to deriving learning for the benefit of other residents.
The inquest also heard evidence that Lisburne Court’s process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care’s employment. It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing.
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Internal incident reporting and escalation process depending largely on an individual manager
Wider context from the report “In the course of the inquest I heard evidence that, whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained injury on 12th April 2017, neither the family nor Borough Care’s corporate risk function had been notified of the circumstances which led to Mrs Smith’s hip fracture. This latter point raises a particular concern as to Borough Care’s ability to undertake any meaningful investigation into the circumstances of Mrs Smith’s injury, with a view to deriving learning for the benefit of other residents.
The inquest also heard evidence that Lisburne Court’s process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care’s employment. It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing.
” 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 Ensure incidents are discussed during audit meetings involving the Quality Manager, Area Support team and Home Manager.
Verbatim wording from the response “Our Quality Manager and Area support team will also ensure that any incidents are discussed on their audit meetings with the Home Manager.” Source location 2017-0397-Response-by-Borough-Care
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 weekly significant-incident reporting form, discuss reported incidents at Care and Quality meetings, and action follow-up through Area Support.
Verbatim wording from the response “I have therefore devised a form that managers must complete on a weekly basis to inform Head of Care of any significant incidents that happen in the home. These incidents are discussed weekly at our Care & Quality meetings and any follow up is actioned by the Area Support for that Home. This form was introduced to all Managers on the 26th October at our monthly Managers meeting and was actioned by the Managers from the following Monday.” Source location 2017-0397-Response-by-Borough-Care
Open published response
22 Jun 2016 Malcolm Bennett · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 1 Delays in arranging emergency hospital assessment and transport after suspected significant injury View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Malcolm Bennett · 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
Malcolm Bennett, a resident of a care establishment, sustained injuries in falls and altercations with other residents. After an alleged assault on 15 December 2015, he was taken to hospital several hours later and died the following day from a head injury; the principal concern was the delay in arranging hospital treatment despite his care plan.
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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Delays in arranging emergency hospital assessment and transport after suspected significant injury
Wider context from the report “In the care Plan for this person, it clearly indicated that in the event of any significant injury he should be taken as expeditiously as possible to the Emergency Dept. of the hospital . Clearly this was not done, in that the staff left him knowing that he had apparently been hit by someone and he might well be injured , and they did not call for an ambulance for another three hours . In the light of his cause of death, this delay might have been contributory.
” 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 Update risk management plans for residents prescribed anticoagulants to require calling 999 immediately after a fall, accident or injury.
Verbatim wording from the response “1. All Home Managers in each of Borough Care's care homes were instructed to update the risk management plans (which form part of a care plan) for all residents who have been prescribed Warfarin or any other anti-coagulant, with an instruction to ring 999 without delay in the event that a resident has, or is suspected of, having had a fall, accident or injury. Registered Managers at all care homes have been asked to confirm that risk management plans for residents prescribed with such medication have now been updated.” Source location 2016-0232-Response-by-Borough-Care
Open published response
Concerns raised 3 Failure of managers to understand their duty to report reportable incidents View source Failure to maintain door-closers in safe working condition and with safe closing strength View source Lack of staff training on what constitutes a reportable incident 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.
×
AI-generated summary
Doris Taylor · 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
Doris Taylor was admitted to a care home after reduced mobility and back pain, having been assessed as at high risk of falling. She suffered three falls, with the second apparently caused by a defective door-closer that knocked her over; the inquest concluded that her death was accidental and recorded pneumonia and multi-organ failure, with a fractured neck of femur among the underlying conditions. The principal concerns were inadequate staff understanding of reportable incidents and unsafe or excessively strong door-closers.
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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure of managers to understand their duty to report reportable incidents
Wider context from the report “1. Staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such .
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain door-closers in safe working condition and with safe closing strength
Wider context from the report “2. The door-closers on all doors in such an establishment should be in a safe working condition, and of such ‘strength’ as to be efficient in causing the door to close yet at the same time not so ‘strong’ as to make it dangerous as they close (as to knock over the person as happened to Mrs Taylor).
” 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 Borough Care Ltd; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training on what constitutes a reportable incident
Wider context from the report “1. Staff training should include a full and clear understanding as to what constitutes a reportable incident and the managers should be aware of their duty to report such.
” 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