Recipient

Bourne House, Old Sarum

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First report 3 Sep 2015•Latest report 3 Sep 2015

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Bourne House, Old Sarum linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    May Hall · 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

    May Hall fell twice during the night of 11/12 April 2015, banging her head on both occasions, and later died from a subdural haematoma. Staff at Bourne House indicated that they were not aware of a policy for reporting falls or calling an ambulance or emergency doctor, and the report identified a need for clear, regularly reviewed staff training on responding to 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 Bourne House, Old Sarum; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to regularly review fall-response training

    Wider context from the report

    “The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”
    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 Bourne House, Old Sarum; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff awareness of the policy for calling the ambulance or emergency doctor after a fall

    Wider context from the report

    “The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”
    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 Bourne House, Old Sarum; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear staff training on addressing falls

    Wider context from the report

    “The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”
    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 Bourne House, Old Sarum; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff awareness of the policy for reporting falls

    Wider context from the report

    “The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”
    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 Bourne House, Old Sarum; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain staff confirmation of receipt of fall-response training

    Wider context from the report

    “The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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