23 Jul 2019 Barbara Humphreys · Prevention of Future Deaths report South Wales Central
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Concerns raised 10 Failure to fully involve families in palliative care or DNAR decision-making View source Delays in completing care plans and best interests assessments View source Failure to provide families with sufficient information about palliative care or DNAR decisions View source Use of mattresses unsuitable for particular beds or unable to maintain patient limbs within the mattress area View source Failure to include willing patient family members in bed rail risk assessments View source Lack of adequate staff training in bed rail and accompanying bedding arrangements View source Failure to complete full and frank bed rail risk assessments View source Lack of an implemented full bed rail policy governing regulatory compliance View source Failure to inform family and next of kin about medically trained professional attendance or review View source Failure to review bed rail risk assessments regularly View source See 7 more concerns
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.
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AI-generated summary
Barbara Humphreys · 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
Barbara Humphreys was admitted to Crosfield House in July 2018 and later experienced repeated entrapment of her leg and foot between bed rails and the mattress. She underwent a right lower-leg amputation and died in hospital on 28 November 2018; the reported medical cause was thrombosis and the inquest conclusion was natural causes. The principal concerns included the lack of a bed-rail risk assessment, unsuitable mattresses, staff training, bed-rail policies, care planning, and communication with family about medical attendance, palliative care and DNAR decisions.
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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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to fully involve families in palliative care or DNAR decision-making
Wider context from the report “7. The seventh issue is directed to National Health Service Wales who should consider and if so appropriate draft and implement a policy to ensure that families of those assigned to palliative care and/or made subject to DNAR orders are provided sufficient information about how that decision has been made, that they as a family have been fully involved in the decision-making process and upon what information it has been made such as the limits of patient confidentiality may allow in the circumstances.
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Delays in completing care plans and best interests assessments
Wider context from the report “5. The fifth issue is directed to Crosfield house Ltd and Care Inn limited which is there was evidence that the completion of care plans and best interests assessments was required to be fitted round other duties and as such may not be completed in a timely fashion . The group and the care home shall consider whether assigning a set or allotted period of time for a RGN to complete the care plan and assessment in the working day would help ensure that the care plan is most accurate and appropriately detailed.
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with sufficient information about palliative care or DNAR decisions
Wider context from the report “7. The seventh issue is directed to National Health Service Wales who should consider and if so appropriate draft and implement a policy to ensure that families of those assigned to palliative care and/or made subject to DNAR orders are provided sufficient information about how that decision has been made , that they as a family have been fully involved in the decision-making process and upon what information it has been made such as the limits of patient confidentiality may allow in the circumstances.
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Use of mattresses unsuitable for particular beds or unable to maintain patient limbs within the mattress area
Wider context from the report “1. The first issue is directed to Crosfield house Ltd and Care Inn limited and Care Inspectorate Wales. It relates to the use of mattresses which are either not designed for use on particular beds or when used on particular beds are not constructed or designed to maintain a level when a patient is placed in the centre of said mattress. Upon placing of a patient in the centre of said mattress certain mattresses can fold at the edge and otherwise become displaced such that a patient’s limbs will not be maintained within the mattress area . The correct mattress for the correct bed is considered de minimus in terms of a standard
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to include willing patient family members in bed rail risk assessments
Wider context from the report “3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails. This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly.
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate staff training in bed rail and accompanying bedding arrangements
Wider context from the report “2. The second issue is also directed to Crosfield house Ltd and Care Inn limited and requires adequate training to be provided to all employees in the homes operated by your respective companies. The training should include the selection, fitting, management and review of bed rails and accompanying bedding arrangements .
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to complete full and frank bed rail risk assessments
Wider context from the report “3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails . This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly.
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of an implemented full bed rail policy governing regulatory compliance
Wider context from the report “4. The fourth issue is directed to Crosfield house Ltd and Care Inn limited. The company should produce and implement a full bed rail policy which is either group wide or relevant specific only to Crosfield house Ltd. This should detail how the company intends to ensure their employees are following the letter and spirit of the regulations .
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family and next of kin about medically trained professional attendance or review
Wider context from the report “6. The sixth issue is directed to Care Inspectorate Wales and National Health Service Wales. They shall consider and if so appropriate, draft and implement a policy which requires a care home or care provider to inform the family and next of kin of events in which are medically trained professional has attended to or seen the patient particularly in cases where there is no or varying capacity .
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to review bed rail risk assessments regularly
Wider context from the report “3. The third issue is also directed to Crosfield house Ltd and Care Inn limited. The staff and care homes in general under your control should complete a full and frank risk assessment in relation to any and all issues with regards to bed rails. This should be conducted with the input and knowledge of a patient’s family members, if they so wish and the risk assessment should be reviewed regularly .
” Open source report
27 Jul 2017 Percy Jacks · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 6 Reliance of GP prescribing on receipt of hospital scan-result notification View source Haphazard DVT management system View source Failure of the hospital-to-GP DVT result communication system View source Failure to reliably communicate medication and clinical plans from hospital to care home View source Lack of medication review for correct Rivaroxaban dosage and duration View source Fragile communication system between GP, hospital and care home View source See 3 more concerns
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.
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AI-generated summary
Percy Jacks · 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
Percy Jacks died from a pulmonary embolus after being found unresponsive the morning following treatment for chest pain. The report identified failings in the management of his anticoagulation medication, including poor communication between the hospital, GP surgery and care home, and inadequate systems for ensuring the medication continued for the intended period.
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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Reliance of GP prescribing on receipt of hospital scan-result notification
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital . There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed.
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Haphazard DVT management system
Wider context from the report “(3) The evidence revealed a view from one of the hospital doctors to the effect that DVT management should be undertaken within the hospital setting rather than by the GP’s to ensure that a comprehensive and failsafe system operated rather than the somewhat haphazard one revealed by the evidence .
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure of the hospital-to-GP DVT result communication system
Wider context from the report “(1) The investigation revealed that the system for the Bronglais Hospital contacting the GP was poor. The result of the DVT scan which took place on 6 February was sent to the incorrect GP surgery and despite an explanation as to why that happened no satisfactory explanation could be found.
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to reliably communicate medication and clinical plans from hospital to care home
Wider context from the report “(4) The evidence further revealed a practice of sending details of the medication and clinical plan back with the driver of the patient who had taken the patient back from hospital to the care home.
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of medication review for correct Rivaroxaban dosage and duration
Wider context from the report “(2) The system within the GP surgery for prescribing Rivaroxaban was poor and relied solely on receiving the notification of the results of the scan from the hospital. There was no facility to review the medication to ensure that the correct dosage for the correct period of time continued to be prescribed .
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Fragile communication system between GP, hospital and care home
Wider context from the report “(5) Overall the evidence revealed a very fragile system of communication between GP hospital and care home in circumstances in which the deceased had moved between three care homes in a short period of time.
” Open source report
Concerns raised 4 Inadequate monitoring of INR levels View source Inadequate communication about anticoagulation monitoring and potential therapy adjustment View source Lack of certainty whether Warfarin was being taken View source Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment View source See 1 more concern
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
Mrs. Mary Patricia James · 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
Mrs. Mary Patricia James had a prosthetic heart valve requiring anticoagulation, but INR monitoring was inadequate and there was uncertainty about whether she was taking Warfarin. Concerns included failures in communication between the INR Unit, care home and GP, and that she was not admitted to hospital on 15 May 2015 despite concern about a possible ischaemic leg. The inquest concluded: “Ischaemic leg contributed to by inadequate Warfarin monitoring and dosing”.
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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Inadequate monitoring of INR levels
Wider context from the report “(1) Inadequate monitoring of INR levels in a patient suffering from dementia;
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication about anticoagulation monitoring and potential therapy adjustment
Wider context from the report “(3) Inadequate communication between the INR Unit, the Care Home and the GP regarding this patient’s anticoagulation monitoring and the potential need for therapy adjustment ;
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Lack of certainty whether Warfarin was being taken
Wider context from the report “(2) Lack of certainty whether Warfarin was being taken by the patient ;
” 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 Care Inspectorate Wales; that does not assign responsibility.
PFD Monitor interpretation Failure to admit a patient to hospital when a possible ischaemic leg requires assessment and anticoagulation adjustment
Wider context from the report “(4) That against this background and the Care Home’s concern about a possible ischaemic leg , Mrs. James was not admitted to hospital on the 15th May, 2015 when there may have been a window of opportunity to have adjusted the anticoagulation therapy .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations