31 Jul 2023 Eileen Marguerite WALSH · Prevention of Future Deaths report Norfolk
View report summary
Concerns raised 13 Failure of senior management to understand record-system editing capability View source Failure to address falls risks and faulty sensor mats View source Failure to complete and define a night staff task list View source Failure to review relevant care notes during incident investigations View source Lack of clear rules on sleeping during night-shift breaks View source Failure of home audits to identify care concerns View source Failure of warning alarms to support immediate response throughout the care home View source Failure to complete a night working policy View source Failure to accept and learn from identified care concerns View source Failure to restrict care staff from editing records View source Unavailability of an electronic system to monitor checks on residents View source Failure to appropriately identify and refer safeguarding concerns View source Failure to take effective action on poor staff performance and learn lessons View source See 10 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. 13
Action
Review the Staff Induction Record and implement additional staff observation reports.
Stated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Continue monthly management spot checks and periodically work night shifts to observe and support staff practice.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 August 2023. View source
Action
Arrange monthly visits from the external compliance company to identify continuous-improvement needs and support new systems and processes.
Stated plannedThe respondent said that this action was planned when they made their response on 4 August 2023. View source
Action
Add sounders near Rooms 1 and 2 and test alarms to ensure emergency signals can be heard across the home.
Stated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Require staff to communicate and manage laundry and medication-room work so resident care, alarm audibility and staff availability are maintained.
Stated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Report medication near misses as safeguarding concerns going forward.
Stated plannedThe respondent said that this action was planned when they made their response on 4 August 2023. View source
Action
Increase maintenance alarm checks from monthly to weekly and replace faulty sensor mats immediately, with additional resident observations until repairs are completed.
Stated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Upload the Night Working Policy to the QCS system and staff reading list, and make it available in the staff area.
Stated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Install and operate a monitoring system linking room-entry records, sensor mats, audible alarms and response-time reporting.
Stated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Use walkie-talkies to coordinate night staff movements and communication throughout the building.
Stated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Consolidate night-work guidance, checklists, handover requirements and alarm procedures within the Night Working Policy and Procedure.
Stated completedThe respondent said that this action was complete when they made their response on 4 August 2023. View source
Action
Provide practical safeguarding and whistleblowing training, including scenario-based exercises, and discuss the Night Working Policy at staff meetings.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 August 2023. View source
Action
Check sensor mats three times daily and record testing, faults, replacements and handover information.
Stated in progressThe respondent said that this action was in progress when they made their response on 4 August 2023. View source See 10 more actions
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AI-generated summary
Eileen Marguerite 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
Eileen Marguerite WALSH, who had dementia and general frailty, fell unwitnessed at Broadland View Care Home, sustained a fractured neck of femur, and died on 3 March 2020. The inquest found that required hourly checks were not completed, her bed was not lowered, and the PIR sensor and pressure mat alarms did not sound; her death was contributed to by neglect. Concerns included incomplete night-working and monitoring arrangements, unreliable or editable care records, unclear policies on sleeping during night shifts, alarms that could not be heard everywhere, and failures to identify and learn from care and safeguarding concerns.
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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of senior management to understand record-system editing capability
Wider context from the report “4. An investigation carried out by the Home found that records had been edited and some falsified by a member of staff. A statement made by the new Deputy Manager at the Home dated 14 July 2023 stated that only senior management could go into the system to edit existing records. Evidence was heard at the inquest from the Registered Manager who stated that care staff can access and edit the records. It is a concern that senior management are unaware the system can be edited as well as a concern that it is acceptable for staff to edit entries.
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to address falls risks and faulty sensor mats
Wider context from the report “8. The Care Quality Commission carried out an inspection in February 2023, nearly 3 years following Mrs Walsh’s death, and raised similar concerns as raised during this inquest, including:
a) Safeguarding concerns had not always been appropriately identified and referred
b) Risks relating to falls were not dealt with , including a faulty sensor mat was still in place some days later
c) Since a historic issue of staff neglect, further incidents of poor staff performance were identified and effective action had not always been taken. It is stated this failure to learn lessons placed people at risk of harm
d) Recent audits carried out by the Home had not identified concerns found by the CQC
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and define a night staff task list
Wider context from the report “3. Evidence was heard that carers are responsible for work alongside caring for residents, including cleaning and laundry, A Night Tasks List was referred to as being “currently under review” and under the heading “Actions” was included “Implement revised night staff task list” in an investigation carried out by Adult Safeguarding in an Adult Safeguarding Record from 2022. As at the date of the inquest this document was not complete . There was no evidence as to what this List would include .
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to review relevant care notes during incident investigations
Wider context from the report “7. The Director of Training and Operations referred to the Incident Investigation carried out internally and found that PIR sensors were not in use in Mrs Walsh’s room at the time of her fall. PIR sensors were referred to in witness evidence and also in Mrs Walsh’s Daily Care Notes. It was found at the inquest a PIR sensor was in Mrs Walsh's room at the time of her fall and the PIR sensor did not sound an alarm as required in the Care Plan, at the time of Mrs Walsh’s fall. It is a concern this investigation did not read Mrs Walsh’s Care Notes before reaching this conclusion when concerns that the PIR sensor did not sound could have been addressed.
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Lack of clear rules on sleeping during night-shift breaks
Wider context from the report “5. Conflicting evidence was heard as to whether night staff are allowed to sleep during breaks whilst on night shift .
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of home audits to identify care concerns
Wider context from the report “8. The Care Quality Commission carried out an inspection in February 2023, nearly 3 years following Mrs Walsh’s death, and raised similar concerns as raised during this inquest, including:
a) Safeguarding concerns had not always been appropriately identified and referred
b) Risks relating to falls were not dealt with, including a faulty sensor mat was still in place some days later
c) Since a historic issue of staff neglect, further incidents of poor staff performance were identified and effective action had not always been taken. It is stated this failure to learn lessons placed people at risk of harm
d) Recent audits carried out by the Home had not identified concerns found by the CQC
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of warning alarms to support immediate response throughout the care home
Wider context from the report “6. The warning alarms requiring immediate response cannot be heard in all places at the Care Home . It is understood walkie-talkies have been introduced for use by all staff but this adds in another step to be taken by staff before the alarm is responded to .
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to complete a night working policy
Wider context from the report “1. A Night Working Policy was being prepared but this is still not completed some 3 years following Mrs Walsh’s death.
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to accept and learn from identified care concerns
Wider context from the report “9. The Registered Manager did not accept many of the concerns raised by the CQC during their attendance and this is a missed opportunity to learn lessons, improve care and prevent future deaths .
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to restrict care staff from editing records
Wider context from the report “4. An investigation carried out by the Home found that records had been edited and some falsified by a member of staff. A statement made by the new Deputy Manager at the Home dated 14 July 2023 stated that only senior management could go into the system to edit existing records. Evidence was heard at the inquest from the Registered Manager who stated that care staff can access and edit the records . It is a concern that senior management are unaware the system can be edited as well as a concern that it is acceptable for staff to edit entries .
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Unavailability of an electronic system to monitor checks on residents
Wider context from the report “2. Evidence was heard that a new electronic system to monitor checks on residents was being sourced . This is not in place some 3 years following Mrs Walsh's death.
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately identify and refer safeguarding concerns
Wider context from the report “8. The Care Quality Commission carried out an inspection in February 2023, nearly 3 years following Mrs Walsh’s death, and raised similar concerns as raised during this inquest, including:
a) Safeguarding concerns had not always been appropriately identified and referred
b) Risks relating to falls were not dealt with, including a faulty sensor mat was still in place some days later
c) Since a historic issue of staff neglect, further incidents of poor staff performance were identified and effective action had not always been taken. It is stated this failure to learn lessons placed people at risk of harm
d) Recent audits carried out by the Home had not identified concerns found by the CQC
” 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 Broadland View Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to take effective action on poor staff performance and learn lessons
Wider context from the report “8. The Care Quality Commission carried out an inspection in February 2023, nearly 3 years following Mrs Walsh’s death, and raised similar concerns as raised during this inquest, including:
a) Safeguarding concerns had not always been appropriately identified and referred
b) Risks relating to falls were not dealt with, including a faulty sensor mat was still in place some days later
c) Since a historic issue of staff neglect, further incidents of poor staff performance were identified and effective action had not always been taken . It is stated this failure to learn lessons placed people at risk of harm
d) Recent audits carried out by the Home had not identified concerns found by the CQC
” 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 Review the Staff Induction Record and implement additional staff observation reports.
Verbatim wording from the response “v. As part of lessons learnt, the Staff Induction Record has undergone another review and additional observation reports for staff have been implemented.
vi. The Care Manager will refer staff that have been dismissed sooner to the Disclosure and Barring Service, if appropriate and did this in November 2022 when a longstanding member of staff block booked too many observations after they had taken place.
(8d). Recent audits carried out by the Home had not identified concerns found by the CQC during their attendance” Source location Response from Broadland View Care Home
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 Continue monthly management spot checks and periodically work night shifts to observe and support staff practice.
Verbatim wording from the response “V. The Care Manager and Deputy continue to complete 2 to 3 spot checks a month.” Source location Response from Broadland View Care Home
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 Arrange monthly visits from the external compliance company to identify continuous-improvement needs and support new systems and processes.
Verbatim wording from the response “We have recently engaged them to do a more thorough 3-day inspection and are arranging monthly visits from them going forward to assist the Care Manager in identifying areas of continuous improvement and putting in new systems and processes in place, as required, and are appropriate to the service. The DTO from Careskills Academy is a source of remote advice and support and uses their knowledge of the health and social care sector to build systems, processes and reporting tools should they be needed to improve the service further. They meet with the Care Manager on a weekly basis to determine what actions are needed and discuss the completion of compliance records. This is a source of support for the Care Manager in keeping all parts of the service on track.” Source location Response from Broadland View Care Home
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 sounders near Rooms 1 and 2 and test alarms to ensure emergency signals can be heard across the home.
Verbatim wording from the response “XII. The new alarm system has been installed, and the Night Working Policy has been updated to include this.” Source location Response from Broadland View Care Home
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 Require staff to communicate and manage laundry and medication-room work so resident care, alarm audibility and staff availability are maintained.
Verbatim wording from the response “III. Medication is administered from a mobile secure medication trolley, and the only time that the Senior carer is in the Medication Room is to collect and return the trolley. They are instructed to have the door open whilst they collect and remove the trolley then close and lock it afterwards. Audits on controlled drugs and homely remedies is only completed when both management are on site ensuring that a senior member of staff is able to hear the alarm. Interim monitor system was installed into the medication room until the new monitoring system was fitted.” Source location Response from Broadland View Care Home
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 Report medication near misses as safeguarding concerns going forward.
Verbatim wording from the response “9. The Registered Manager did not accept many of the concerns raised by the CQC during their attendance and this is a missed opportunity to learn lessons, improve care and prevent future deaths.
I. The Registered manager has accepted the concerns raised and did apologise on the day of inspection for any actions of concern missed.
II. There was a lesson learnt as the Care Manager was not aware that ‘near misses’ should be raised as Safeguarding. The Care Manager will report these going forward. It is not something they were aware that had to be done in all their years of care experience and training completed. This is the lesson learnt.
III. There were concerns over the staff member that was dismissed not signing some meeting notes. The Care Manager apologised and explained that the staff member was suspended and dismissed before there was an opportunity to get the notes signed.” Source location Response from Broadland View Care Home
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 Increase maintenance alarm checks from monthly to weekly and replace faulty sensor mats immediately, with additional resident observations until repairs are completed.
Verbatim wording from the response “On the daily checks recorded by the seniors, the mat was then reported as working until 10.02.2023 when there was a fault mended by Maintenance. The mat was reported as working every day from 10.02.2023 up until the inspection on 20.02.2023. It was working on 19.02.2023 when tested which was the day before the inspector arrived.
iii. Sensor mats are checked 3 times a day, once by the day senior, once by the night senior, which is recorded on the Senior Task Checklist and then again by the Care Manager/Deputy on their daily walk round. The Maintenance team alarm checks have now been increased from Monthly to Weekly. If mats require changing, they have always been documented either on the senior task list, the managers walk round, or the maintenance checklist, dependent on who changes the mat. This information is also handed over on the handover report.” Source location Response from Broadland View Care Home
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 Upload the Night Working Policy to the QCS system and staff reading list, and make it available in the staff area.
Verbatim wording from the response “I. The Night Working Policy is a recent part of our continuous improvement and not part of the improvements 3 years ago. In our experience, it is not usual that a Care Home has a specific Night Work Policy. We chose to write this policy recently because of all the improvements that we have made over the last 3 years, and we wanted to consolidate all the work, where it related to Night Work specifically, into one policy.” Source location Response from Broadland View Care Home
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 Install and operate a monitoring system linking room-entry records, sensor mats, audible alarms and response-time reporting.
Verbatim wording from the response “V. New monitoring system: This is part of our continuous improvement plans. The Medication system means that accurate recording of room checks, and response times will all be documented, and a detailed report can be obtained. There are sounders in all locations within the home ensuring that all staff can always hear the emergency alarms during their shift.” Source location Response from Broadland View Care Home
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 Use walkie-talkies to coordinate night staff movements and communication throughout the building.
Verbatim wording from the response “- Daily notes audit: to monitor and audit night observations
- Walkie Talkies: to enhance communication between staff and work in every area of the building
Further actions taken:
- additions made to ensure that staff limit the time in laundry/medication room
- Daily audit of handover, this includes call mats.
- 2nd line sampling of daily notes audit by the Care Manager
- If there is a discrepancy in the night checks, staff are required to explain why and complete an incident form around this.
- Interim monitor system put into Laundry and Meds room so that alarms can be heard.
- Alarms tested to ensure that they can be heard from all rooms.” Source location Response from Broadland View Care Home
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 Consolidate night-work guidance, checklists, handover requirements and alarm procedures within the Night Working Policy and Procedure.
Verbatim wording from the response “II. Broadland View decided as a part of continuous improvement to have some enhanced actions they could take, to bring together the learning and information that night staff specifically need, into this policy.” Source location Response from Broadland View Care Home
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 Provide practical safeguarding and whistleblowing training, including scenario-based exercises, and discuss the Night Working Policy at staff meetings.
Verbatim wording from the response “VIII. Managers discuss the new Night Work policy at staff meetings.” Source location Response from Broadland View Care Home
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 Check sensor mats three times daily and record testing, faults, replacements and handover information.
Verbatim wording from the response “On the daily checks recorded by the seniors, the mat was then reported as working until 10.02.2023 when there was a fault mended by Maintenance. The mat was reported as working every day from 10.02.2023 up until the inspection on 20.02.2023. It was working on 19.02.2023 when tested which was the day before the inspector arrived.
iii. Sensor mats are checked 3 times a day, once by the day senior, once by the night senior, which is recorded on the Senior Task Checklist and then again by the Care Manager/Deputy on their daily walk round. The Maintenance team alarm checks have now been increased from Monthly to Weekly. If mats require changing, they have always been documented either on the senior task list, the managers walk round, or the maintenance checklist, dependent on who changes the mat. This information is also handed over on the handover report.” Source location Response from Broadland View Care Home
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 The medication events were near misses, not medication errors, and residents received the medication safely.
Verbatim wording from the response “a) Safeguarding concerns had not always been appropriately identified and referred
I. The Safeguarding concerns referred to involved one member of staff. The Care Manager apologised on the day of inspection and notifications rectified.
II. The Care Manager questioned the Inspector because medication errors referred to were proven to be ‘near misses’ so no errors were made and therefore this was the reason that a safeguarding was not made. The Inspector said that ‘near misses’ must also be raised as safeguarding, which is not something that is usually done. We would like to reiterate that the medication in question was successfully and safely taken by residents.
III. This member of staff had given poor personal care on one shift which was addressed and did not happen again. The manager apologised for not raising a safeguarding on this occasion and this was subsequently done.
IV.” Source location Response from Broadland View Care Home
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 The absence of a specific night-work policy did not leave relevant guidance unavailable; existing induction, training and practice already provided the information.
Verbatim wording from the response “I. The Night Working Policy is a recent part of our continuous improvement and not part of the improvements 3 years ago. In our experience, it is not usual that a Care Home has a specific Night Work Policy. We chose to write this policy recently because of all the improvements that we have made over the last 3 years, and we wanted to consolidate all the work, where it related to Night Work specifically, into one policy.” Source location Response from Broadland View Care Home
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 CareDocs edit functionality cannot be removed because staff need edit rights to complete required care records.
Verbatim wording from the response “VII. The former registered Care Manager and former Deputy also undertook daily audits of the system which were immediately put into place after the incident when they found that real time records could be found for the night observations. The Daily notes audits have been ongoing daily since the incident. We have found no edits made for night observations, except for the falsification of records by the member of staff that was prosecuted.” Source location Response from Broadland View Care Home
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 Sensor-mat risks are addressed through checks three times daily, immediate replacement, increased observations and maintenance arrangements.
Verbatim wording from the response “This member of staff was suspended after the medication near misses, investigated, then dismissed and reported to the Disclosure and Barring Service, before the CQC inspection took place.
(8b) Risks relating to falls were not dealt with, including a faulty sensor mat was still in place some days later.
I. On the day of inspection, a sensor mat was found to be faulty and changed immediately, as is normal practice. The Care Manager had not done their daily walk round of the service when they test the sensor mats, because of the arrival of the CQC Inspector.
II. It is common in care that sensor mats can become faulty or stop working, and there is a process in place for testing and replacing them. For the mat in question there had been a fault recorded on 27.01.2023 where the mat and the box had been replaced on the 28.01.2023 by the maintenance team.” Source location Response from Broadland View Care Home
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 Recent audits did identify relevant issues; the inspection did not review the daily notes audit and disputed report terminology caused confusion.
Verbatim wording from the response “i. Daily notes audits are carried out daily and pick up in real time when observations are entered. On the day of inspection, the CQC Inspector asked to see the night spot checks, which were shown. This is a record of what happened at that moment in time when the Manager appears unannounced in” Source location Response from Broadland View Care Home
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations