21 Apr 2016 Mary Walker · Prevention of Future Deaths report Manchester West
View report summary
Concerns raised 2 Failure to record patients’ condition during night-time checks View source Lack of clear procedures for Care Assistants escalating health concerns View source
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
Mary Walker · 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
Mary Walker, who had dementia and had been admitted to hospital after a stroke before being discharged to a care setting, was found dead on 10 October after overnight checks. She had died of bronchopneumonia. Concerns were raised about the lack of detail recorded during night-time checks and unclear procedures for Care Assistants escalating health concerns.
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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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to record patients’ condition during night-time checks
Wider context from the report “(1) At the inquest there was no specific evidence about what was revealed in the night time checks that had been carried out upon the deceased . There was a global summary stating the times at which checks had been carried out but there was no information as to what the patient’s condition was at the checks . This procedure requires review.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of clear procedures for Care Assistants escalating health concerns
Wider context from the report “(2) During the inquest there was a lack of clarity in relation to the procedures to be followed by Care Assistants when they wanted to escalate health concerns . This system requires review.
” 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 Undertake a comprehensive ratings inspection of Belong Wigan Care Village, including review of the provider’s response to the report findings.
Verbatim wording from the response “Following receipt of this Report we held a management review meeting to look at the information we held in relation to this case. At this meeting we took the decision to:” Source location 2016-0150-Response-by-Care-Quality-Commission
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 provider’s response and inspection consideration were sufficient, so no written confirmation or further action evidence was requested.
Verbatim wording from the response “We noted the response provided to you by the registered provider, CLS Care Services Limited known as Belong on 27 April 2016. In light of this response it was not felt necessary for CQC to contact the registered provider to request written confirmation and” Source location 2016-0150-Response-by-Care-Quality-Commission
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 Following inspection and document review, no further investigation into the death or regulated activities was considered necessary.
Verbatim wording from the response “Thank you for providing us with disclosure during the Coronial investigation. We can confirm that following our inspection and a review of these documents we do not intend to undertake further investigations in relation to the death of Mary Walker or the provision of regulated activities by CLS Care Services Limited.” Source location 2016-0150-Response-by-Care-Quality-Commission
Open published response
Concerns raised 4 Failure to follow NICE guidelines View source Failure to maintain appropriate records View source Failure to follow NMC guidance View source Failure to develop appropriate care plans 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
Dorothy Imsson · 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
Dorothy Imsson died at Cleveleys Nursing Home on 9 August 2014 from a naturally occurring stroke caused by atrial fibrillation. Her death was contributed to by the absence of pressure care planning by qualified staff, resulting in severe skin ulceration, a shortening of life, and increased pain and suffering. Concerns also included the District Nursing Service's failure to develop an appropriate care plan and alleged failures to follow NMC guidance, record-keeping requirements, and NICE guidelines.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NICE guidelines
Wider context from the report “(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain appropriate records
Wider context from the report “(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to follow NMC guidance
Wider context from the report “(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to develop appropriate care plans
Wider context from the report “(1) No appropriate care plan was developed by the District Nursing Service.
(2) The District Nursing Service are compromising patient care by not following NMC guidance or record keeping
(3) The District Nursing Services are compromising patient care by not following NICE guidelines.
” Open source report
16 Mar 2016 Steven James May · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 10 Inadequate First Aid training for prison staff View source Selective emergency First Aid training among prison staff View source Lack of mental health experience and/or training among reception nursing staff View source Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process View source Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone View source Failure to ensure medical professional attendance at First Care Reviews View source Failure of reception nursing staff to consult historical medical notes during reception interviews View source Limited accessibility of health and/or mental health care during weekends and Bank Holidays View source Reliance on verbal handovers rather than written records for prisoner information View source Failure to prepare sufficiently full ACCT assessment notes 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.
×
AI-generated summary
Steven James May · 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
Steven James May died by hanging at HMP Ranby on 25 May 2015 at 01:45, after previously expressing suicidal intent and being placed on the ACCT programme. The report identified concerns about failures in reception health screening, ACCT documentation and reviews, information handovers, staff training and involvement, emergency first aid, cell-entry procedures, and access to health and mental health care.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inadequate First Aid training for prison staff
Wider context from the report “(9) The inadequacy of First Aid training provided to prison staff in any event (namely, the administration of CPR by prison staff whilst the deceased was lying on a bed );
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Selective emergency First Aid training among prison staff
Wider context from the report “(7) The selective training of prison staff in emergency First Aid (namely the first member of prison staff on the scene of the death was not trained in the administration of CPR and was ignorant of the location of and method of use of defibrillators );
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of mental health experience and/or training among reception nursing staff
Wider context from the report “(2) The lack of experience and/or training of reception nursing staff in the field of mental health ;
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Involvement of prison staff lacking relevant training or appropriate rank in the ACCT process
Wider context from the report “(5) The involvement in the ACCT process of prison staff possessing neither relevant training nor the appropriate rank ;
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Hesitancy to enter a cell during an emergency because of an instruction not to enter cells alone
Wider context from the report “(8) The hesitancy of the first member of prison staff on the scene to enter the deceased’s cell in apparent adherence to an instruction not to enter cells alone ;
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure medical professional attendance at First Care Reviews
Wider context from the report “(6) The failure of prison staff to ensure the attendance of a medical professional at the First Care Review ;
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of reception nursing staff to consult historical medical notes during reception interviews
Wider context from the report “(1) The failure of reception nursing staff , by reason of lack of training and/or instruction or lack of staff and/or time , to consult the deceased’s historical medical notes prior to or during the reception interview ;
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Limited accessibility of health and/or mental health care during weekends and Bank Holidays
Wider context from the report “(10) The accessibility of health and/or mental health care to inmates at weekends and during Bank Holidays .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Reliance on verbal handovers rather than written records for prisoner information
Wider context from the report “(4) Reliance by prison staff on verbal and/or oral handovers of information, rather than written records , regarding the deceased ;
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare sufficiently full ACCT assessment notes
Wider context from the report “(3) The failure of prison staff when preparing the ACCT document to prepare as full a note as possible . For example, to follow the subject areas suggested in the narrative accompanying sections 1-8 of the Assessment Interview ;
” Open source report
12 Feb 2016 Mr. Terence Brooks · Prevention of Future Deaths report Avon
View report summary
Concerns raised 2 Lack of a procedure for investigating the cause of Legionella infection View source Failure to correctly interpret microbiological water-sample results and testing limitations 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
Mr. Terence Brooks · 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
Mr. Terence Brooks, who was being treated for acute myeloid leukaemia, developed Legionella pneumophila pneumonia and died on 23 July 2015. The report raised concerns that the hospital misinterpreted microbiological testing, conducted its investigation on a false premise, and had no procedure for investigating the cause of a Legionella infection.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a procedure for investigating the cause of Legionella infection
Wider context from the report “(4) The hospital, although responding promptly to the infection, had no procedure in place detailing how the investigation of the cause of a legionella infection should be undertaken .
(5) The hospital should put in place an approved procedure for the investigation of any future outbreaks of Legionella infection should they occur. This procedure should describe and define clearly inter alia the nature, limitations and interpretation of the results of any microbiological testing undertaken.
(6) The responsibility for putting such a procedure in place should be that of the Director of Infection Prevention and Control who, in drafting the procedure, should seek the support and guidance of appropriate professionals including Public Health England and the Health Safety Executive.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to correctly interpret microbiological water-sample results and testing limitations
Wider context from the report “(1) Those who conducted the investigation and root cause analysis on the part of the hospital did not appreciate that notwithstanding the absence of the specific subgroup of Legionella serotype 1 in the water samples from the ward as compared to samples from the deceased that this was not conclusive as to the ward not being the source of the infection .
(2) There was a lack of understanding on the part of the hospital as to how to interpret the results of the microbiological analysis of the water samples and the limitations of testing including the meaning of any results obtained, the reliability which may be placed on those results and any conclusions which may be drawn from those results.
(3) As a result of this lack of understanding the hospital misinterpreted the results and conducted their investigation and root cause analysis on a false premise which led them to conclude incorrectly that the William Budd ward was not the source of the Legionella infection.
” Open source report
8 Jan 2016 Norman Dorn · Prevention of Future Deaths report Cornwall
View report summary
Concerns raised 2 Lack of appropriate care-home resuscitation policies and staff preparation to preserve life View source Lack of adequate care-home policies and staff preparation for recognising or arranging confirmation of death 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
Norman Dorn · 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
Norman Dorn was found presumed dead in an armchair at a residential home after eating a jam sandwich, with food in his mouth. He was known to have swallowing problems, and staff did not remove the food or attempt resuscitation; the report also states that the GP and other emergency services did not attend in a timely manner. The concerns included whether care homes had adequate policies and staff training for recognising or confirming death and for resuscitation.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate care-home resuscitation policies and staff preparation to preserve life
Wider context from the report “2. That some care home in Cornwall may not have an appropriate resuscitation policy in place to ensure that all attempts have been made to preserve life (when appropriate) . If such policies are in place that they are regularly updated and staff are made aware of them and given the appropriate training .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of adequate care-home policies and staff preparation for recognising or arranging confirmation of death
Wider context from the report “1. That some care homes in Cornwall may not have adequate policies in place for their residence to appropriately recognise or arrange confirmation of death (i.e. when to call Emergency Service and or GP to recognise death ). If such policies are in place that they are regularly updated and the staff are made aware of them and given the appropriate training .
” Open source report
17 Nov 2015 Mr Frank Mellers · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Failure to communicate DNAR decisions to the patient’s family View source Failure of nursing and medical staff to communicate DNAR decisions 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
Mr Frank Mellers · 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
Mr Frank Mellers fell at home on 4 September 2015, fractured his left hip, and was admitted to hospital for surgery. He suffered a cardiac arrest on 17 September 2015 and died that day from congestive cardiac failure, with ischaemic heart disease and the post-operative fracture repair recorded as contributing factors. The concerns included poor communication with his family about his DNAR status and poor communication between nursing and medical staff, including CPR being commenced despite a DNAR being in place.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to communicate DNAR decisions to the patient’s family
Wider context from the report “(1) Evidence emerging from the inquest suggested that the patient’s DNAR status was fixed without any reference to/discussion with his family . It is recognised that this is a medical decision for the physician but good practice and guidelines require that the family be kept up to date with all such decisions .
(2) There was generally poor communication between nursing and medical staff as evidenced during the inquest when a decision was made to attempt resuscitation despite there being a DNAR in place.
(3) In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing and medical staff to communicate DNAR decisions
Wider context from the report “(1) Evidence emerging from the inquest suggested that the patient’s DNAR status was fixed without any reference to/discussion with his family. It is recognised that this is a medical decision for the physician but good practice and guidelines require that the family be kept up to date with all such decisions.
(2) There was generally poor communication between nursing and medical staff as evidenced during the inquest when a decision was made to attempt resuscitation despite there being a DNAR in place .
(3) In light of the inquest findings, you may consider that the guidelines and policy in the issuing and communication of DNAR may need to be examined.
” Open source report
25 Sep 2015 Mrs Violet Cloudsdale · Prevention of Future Deaths report Cumbria
View report summary
Concerns raised 3 Lack of risk assessment for the general use of wheelchair lap-belts View source Failure to identify the consent of wheelchair users or their families to lap-belt use View source Unclear guidance on the lawful use of wheelchair lap-belts 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
Mrs Violet Cloudsdale · 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 Violet Cloudsdale fell unattended from a stationary wheelchair on 11 December 2014, sustaining fractures, and died five days later from bronchopneumonia while being treated in hospital. Concerns included the absence of a risk assessment and consent consideration regarding use of the wheelchair lap-belt, uncertainty about whether lap-belts constituted unlawful restraint, and unclear guidance on their use.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of risk assessment for the general use of wheelchair lap-belts
Wider context from the report “(1) It was confirmed in evidence by ████████ that:
a) Mrs Cloudsdale would have been less likely to have fallen if the lap-belt which was fitted to the wheelchair had been fastened;
b) No risk assessment had been undertaken as to whether the lap-belt should generally have been utilised ;
c) No attempt had been made to identify whether Mrs Cloudsdale or her family would have indeed consented to the lap-belt being fastened to enhance her feeling of safety or security;
d) There was a concern that utilising lap-belts may be construed as applying an unlawful restraint;
e) Guidance on the use of lap-belts is unclear.
A thorough review of your procedures with regard to the use of lap belts fitted to wheel chairs is required.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to identify the consent of wheelchair users or their families to lap-belt use
Wider context from the report “(1) It was confirmed in evidence by ████████ that:
a) Mrs Cloudsdale would have been less likely to have fallen if the lap-belt which was fitted to the wheelchair had been fastened;
b) No risk assessment had been undertaken as to whether the lap-belt should generally have been utilised;
c) No attempt had been made to identify whether Mrs Cloudsdale or her family would have indeed consented to the lap-belt being fastened to enhance her feeling of safety or security ;
d) There was a concern that utilising lap-belts may be construed as applying an unlawful restraint;
e) Guidance on the use of lap-belts is unclear.
A thorough review of your procedures with regard to the use of lap belts fitted to wheel chairs is required.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unclear guidance on the lawful use of wheelchair lap-belts
Wider context from the report “(1) It was confirmed in evidence by ████████ that:
a) Mrs Cloudsdale would have been less likely to have fallen if the lap-belt which was fitted to the wheelchair had been fastened;
b) No risk assessment had been undertaken as to whether the lap-belt should generally have been utilised;
c) No attempt had been made to identify whether Mrs Cloudsdale or her family would have indeed consented to the lap-belt being fastened to enhance her feeling of safety or security;
d) There was a concern that utilising lap-belts may be construed as applying an unlawful restraint ;
e) Guidance on the use of lap-belts is unclear .
A thorough review of your procedures with regard to the use of lap belts fitted to wheel chairs is required.
” Open source report
3 Sep 2015 Ms. Kala Michelle Skinner · Prevention of Future Deaths report Avon
View report summary
Concerns raised 5 Failure to recognise critical clinical red flags View source Failure to audit at least 3% of Clinical Advisor calls every month View source Absence of a safety net to identify potential risks or training needs View source Failure to make sufficient and timely welfare calls when no response is provided View source Failure to provide appropriate safety-focused clinical advice View source See 2 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.
×
AI-generated summary
Ms. Kala Michelle Skinner · 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
On 17 December 2014, Ms. Kala Michelle Skinner experienced breathing difficulties and, after delays and two ambulance dispatches being recalled, was found in cardiac arrest and died at the scene. The report identified missed clinical red flags, inappropriate advice, insufficient and untimely welfare calls, and concerns about training, mentoring, auditing, and resources for Clinical Advisors.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise critical clinical red flags
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased.
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided.
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed.
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs.
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to audit at least 3% of Clinical Advisor calls every month
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased.
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided.
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors . In some months no audits at all have been performed .
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs.
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Absence of a safety net to identify potential risks or training needs
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased.
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided.
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed.
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs .
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to make sufficient and timely welfare calls when no response is provided
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased.
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided .
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed.
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs.
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate safety-focused clinical advice
Wider context from the report “(1) The Clinical Advisor missed critical ‘red flags’ thereby failing to recognise the seriousness of the deceased’s condition
(3) The Clinical Advisor gave inappropriate advice thereby failing to safeguard against the risk deterioration and ensure the safety of the deceased .
(4) There was failure to make sufficient and timely welfare calls when a response could not be provided.
(5) The Trust should review the training and mentoring of all existing Clinical Advisors with a clear and structured programme to regularly assess and re-assess the competencies of the Clinical Advisors.
(6) The Trust should ensure there is proper training, assessment, mentoring and support provided for all newly appointed Clinical Assessors.
(7) The Trust is failing to ensure its own target of auditing every month 3% of the calls of Clinical Advisors. In some months no audits at all have been performed.
(8) In failing to carry such audits the Trust has identified that there are real concerns that there is no safety net in place to identify potential risks or training needs.
(9) The Trust should take immediate steps to ensure the necessary resources are allocated to achieve at least the level of audit the Trust itself has determined necessary.
(10) The Trust should have in place a structured response to actioning any deficiencies identified in such audits whether that be for individual Clinical Assessors or as a professional group including trend analysis.
” Open source report
27 Aug 2015 Eliza Simpson · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 2 Failure to reassess and renew deprivation of liberty safeguarding orders when required View source Lack of CCTV 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
Eliza Simpson · 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
Eliza Simpson left Roseneath Care Home unobserved on 2 April 2015 and was found recently deceased at a local allotment on 6 April 2015. The inquest recorded the medical cause of death as ischaemic heart disease due to coronary artery disease and concluded that the death was accidental. Concerns included the lack of a system to reassess and renew expired deprivation of liberty safeguarding orders and the absence of CCTV, which hampered the police investigation.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to reassess and renew deprivation of liberty safeguarding orders when required
Wider context from the report “(1) The Roseneath Care Home appeared to have no system for ensuring that when deprivation of liberty safeguarding orders expired the client was re-assessed to determine whether the need for an order persisted and, where appropriate, seeking further order . In this case the home would have had no legal authority to hold Mrs. Simpson if she had been detected attempting to leave the premises on the 2nd April 2015. The very act of assessing Mrs. Simpson and renewing an application would have served to enforce to the Care Home and its staff the risk of her absconding and may have resulted in closer observation. Although the Roseneath Care Home has now closed if such a system is not standard in Care Homes this issue may arise elsewhere.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of CCTV
Wider context from the report “(2) The absence of CCTV hampered the Police investigation , although this is unlikely to have contributed to Mrs. Simpson’s death this may not always be the case and did mean that a very vulnerable member of society was left wondering around on her own when she might otherwise have been found with the aid of CCTV footage .
” Open source report
17 Jul 2015 Mr. Masoud Ghaderi · Prevention of Future Deaths report Avon
View report summary
Concerns raised 3 Ward-round planning and preparation relying solely on a brief nursing summary View source Lack of overarching responsibility for reviewing risk assessments View source Inconsistent recording of engagement with service users 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
Mr. Masoud Ghaderi · 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
Mr. Masoud Ghaderi, who had severe depression and was an informal inpatient at Lime Unit, was found hanging by a belt from a bathroom door on 10 April 2014 and died on 12 April 2014 after life support was withdrawn. The report identified concerns about inconsistent records of engagement, the absence of overarching responsibility for reviewing risk assessments, and ward-round reliance on brief nursing summaries that could result in errors or omissions.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Ward-round planning and preparation relying solely on a brief nursing summary
Wider context from the report “(3) The Trust has a comprehensive single care record for each service user. However, the ward rounds rely only on a brief summary prepared by a nurse the night before when that nurse may not have made any entries in the care record nor would be present at the ward rounds . The Trust should review its planning and preparation for ward rounds so that reliance is not placed solely on a brief summary with the inherent risk of errors and omissions .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of overarching responsibility for reviewing risk assessments
Wider context from the report “(2) There was no one member of staff with overarching responsibility for reviewing any risk assessments . Therefore any trends in changing risk, e.g. increasing risk of self-harm or suicide, could not be identified . The Trust should consider designating a member of staff with this responsibility in the same manner as it has one member of staff with responsibility for ensuring the care plan(s) are reviewed and maintained up-to-date.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inconsistent recording of engagement with service users
Wider context from the report “(1) There was inconsistence records of engagement with service users . The Engagement and Observation policy of the Trust should be reviewed to consider how the policy operates and how engagements with service users are to be recorded in a consistent manner with appropriate staff training in application of the policy.
” Open source report
3 Jun 2015 Mr Frederick White · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Failure of triage to undertake further and detailed assessment of spinal injury risk View source Delays in diagnosing suspected spinal cord injury View source Failure to immobilise patients with suspected spinal cord injury during initial examination and assessment 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
Mr Frederick White · 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
Mr Frederick White suffered a fall at a retirement home on 29 March 2015, sustaining a traumatic spinal cord injury, and died on 2 April 2015. The report identified concerns about failures to recognise symptoms of spinal injury and to immobilise him initially and at hospital, with the inquest finding that these collective failures contributed to his death.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of triage to undertake further and detailed assessment of spinal injury risk
Wider context from the report “(2) Evidence emerging from the inquest suggested that the initial failure to immobilise the patient continued when he arrived at Hospital and the triage process failed to adequately assess the risk again . It appears the triage process is heavily reliant upon the handover from the paramedic crew without further and detailed assessment .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in diagnosing suspected spinal cord injury
Wider context from the report “(3) It wasn't until five hours after the initial fall that a suspected spinal cord injury was diagnosed .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to immobilise patients with suspected spinal cord injury during initial examination and assessment
Wider context from the report “(1) Spinal injuries are relatively uncommon but have the potential to cause significant morbidity and mortality if not managed effectively. Mr White was an elderly patient who was at risk of falling during the course of the inquest evidence emerged showing that he had sustained a traumatic injury of significant blunt force trauma. He also gave a description of feelings of numbness and lack of sensation in his legs and there was also a drop in blood pressure, which should have prompted a conservative approach in treating the patient by applying immobilisation on suspicion of spinal cord injury during his initial examination and assessment .
” Open source report
27 May 2015 Oliver Asante-Yeboah · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 1 Lack of formal regulation of non-medical circumcision providers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Oliver Asante-Yeboah · 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
Oliver Asante-Yeboah developed a urinary tract infection and E. coli sepsis after a non-therapeutic circumcision, deteriorated despite treatment and resuscitation attempts, and died. The report raised concern about the lack of formal regulation of non-medical providers of circumcision and stated that the circumcision had contributed to his death.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of formal regulation of non-medical circumcision providers
Wider context from the report “I am concerned that future deaths could occur in similar circumstances, owing to the lack of formal regulation of non-medical providers of circumcision .
” Open source report
×
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 Commission has no regulatory remit over religious circumcisions performed by non-healthcare professionals.
Verbatim wording from the response “The Care Quality Commission is a statutory body and thus its functions, powers and regulatory remit are determined by statute and Regulations. Schedule 1 to the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010 and from 1 April 2015 the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014 define the “regulated activities” the Commission is empowered to regulate.” Source location 2015-0201-Response-by-Care-Quality-Commission
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 Extending regulation to non-healthcare professionals requires amendment by the Secretary of State, not the Commission.
Verbatim wording from the response “In order to extend the Commission’s regulatory remit to cover non-healthcare professionals the 2014 Regulations would require amendment. This is not within the Commission’s power and can only be undertaken by the Secretary of State.” Source location 2015-0201-Response-by-Care-Quality-Commission
Open published response
21 May 2015 Barbara Patterson · Prevention of Future Deaths report Northumberland (North)
View report summary
Concerns raised 6 Delays in ambulance crew handover at hospitals reducing ambulance availability View source Failure of the Pathways system to prompt CPR advice for patients with agonal breathing View source Failure by call handlers to give timely CPR advice View source Delays in ambulance arrival beyond the target response time View source Failure by ambulance dispatchers to dispatch the closest available ambulance View source Shortage of paramedics View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Barbara Patterson · 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 Patterson suffered a cerebral stroke at home on 1 January 2015, fell from a stair lift, and died at Wansbeck Hospital on 2 January 2015. The substantive concerns included the failure to provide timely CPR advice, a fault in the Pathways system relating to agonal breathing, ambulance dispatch and delayed arrival, and wider ambulance service capacity issues.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance crew handover at hospitals reducing ambulance availability
Wider context from the report “6. During the inquest evidence was given that ambulance availability is being jeopardised by crews being delayed at hospital when handing patients over to Accident and Emergency staff .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of the Pathways system to prompt CPR advice for patients with agonal breathing
Wider context from the report “2. During the inquest evidence was given that the Pathways system, a computerised system piloted in the North East and since rolled out for use by 6 other Healthcare Trusts nationally, has a fault in that it does not advise non clinical call handlers to issue CPR advice unless a patient has stopped breathing . This fails to recognise the need for CPR in cases of Agonal (heavy/noisy breathing which is insufficient to sustain life) . This fault was pointed out to Pathways by the Clinical Section Manager for North East Ambulance Service NHS Foundation Trust, prior to the latest update being installed in early 2014 (Update 9). Pathways refused to amend the system. That fault remains in place to date .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure by call handlers to give timely CPR advice
Wider context from the report “1. The failure by the Call Handler to give timely advice in respect of CPR .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Delays in ambulance arrival beyond the target response time
Wider context from the report “4. The target time for the arrival of the ambulance was 8 minutes, this was breached . The ambulance did not arrive for 15 minutes .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure by ambulance dispatchers to dispatch the closest available ambulance
Wider context from the report “3. The failure by the ambulance dispatcher to dispatch an ambulance closer to the deceased’s location
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Shortage of paramedics
Wider context from the report “5. During the inquest evidence was given that there is a national shortage of paramedics, which is particularly acute in the North East .
” 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 Meet with NEAS in September 2015 to discuss staffing levels, vacant posts, recruitment, and service-delivery management.
Verbatim wording from the response “We will be meeting with NEAS in September 2015 to discuss and monitor how they are managing their delivery of the service, what is their current position of staffing levels and identified vacant posts and their current recruitment position.” Source location 2015-0198-Response-by-Care-Quality-Commission
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 Meet with NEAS in September 2015 to discuss patient handover management and collaboration with providers and stakeholders.
Verbatim wording from the response “We will be meeting with NEAS in September 2015 to discuss how they are managing the handover process to A & E services and how they are working collaboratively with all providers and stakeholders to ensure a smooth and timely handover process. In addition, this issue will be reviewed as part of our planned full comprehensive inspection of North East Ambulance Service (NEAS).” Source location 2015-0198-Response-by-Care-Quality-Commission
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 NEAS to provide evidence of how it is mitigating risks in the Pathways system and working with the Pathways programme to improve it.
Verbatim wording from the response “As recognised in your report, the Pathways system is a National Programme, piloted in the North East, which has been introduced in other areas of the country. We have written to NEAS to instruct them to submit evidence of how they are mitigating the risk within the Pathways system and also how they are working with Pathways to improve the system.” Source location 2015-0198-Response-by-Care-Quality-Commission
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 Conduct a comprehensive NEAS inspection covering call-handler support, ambulance dispatch, arrival-time breaches, and patient handover procedures.
Verbatim wording from the response “The CQC intend to carry out a planned comprehensive inspection of North East Ambulance Service (NEAS) as part of its ongoing inspection process. During this inspection we will investigate to what extent and degree call handlers are supported by systems and procedures already in place. We will also require NEAS to furnish oral and written evidence to demonstrate that they understand their role and responsibilities in relation to call handlers and that they provide regular monitoring to ensure that the system is functioning at an appropriate level.” Source location 2015-0198-Response-by-Care-Quality-Commission
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 NEAS to provide evidence on ambulance arrival-time breaches and measures to mitigate or reduce missed targets.
Verbatim wording from the response “of ambulances is appropriate and what, if any, improvements can be made to the current system. We have written to NEAS to instruct them to submit evidence of their current position around breaches of arrival times of their ambulances together with providing evidence of how they are mitigating the risk of or reducing the missed target times of ambulance arrivals.” Source location 2015-0198-Response-by-Care-Quality-Commission
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 Meet with NEAS in September 2015 to discuss management of ambulance dispatch processes.
Verbatim wording from the response “This issue will be included as part of our planned comprehensive inspection and investigated to ascertain whether procedures presently in place by NEAS relating to the dispatch of ambulances is appropriate and what, if any, improvements can be made to the current system. Additionally, we will be meeting with NEAS in September 2015 to discuss how they are managing the process of dispatching ambulances.” Source location 2015-0198-Response-by-Care-Quality-Commission
Open published response
11 Feb 2015 Anne Horner · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 1 Failure of toilet cubicle doors to permit safe access when an occupant is slumped forward View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Anne Horner · 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
Anne Horner was a resident at Oak Lodge Nursing Home when she sustained head injuries in two incidents involving a toilet cubicle door. Following the second incident on 25 March 2014, she was found unresponsive and died at Salford Royal Hospital from a traumatic head injury. The principal concern was that the toilet cubicle door and available clearance may not have adequately accommodated a resident who had fallen or was slumped forward.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of toilet cubicle doors to permit safe access when an occupant is slumped forward
Wider context from the report “4. The evidence at Inquest confirmed that the bathroom facility which included the toilet cubicle was constructed in or about 1988 in compliance with the relevant Planning Permission and Building Regulations. I accept that the facility had been used on many previous occasions without incident. The fact however that a resident sustained injury on two separate occasions within a period of 6 weeks gives rise to concern. I anticipate that there are many establishments within England and Wales where toilet facilities are not dissimilar to those at Oak Lodge Nursing Home. I understand that separate guidance in relation to disabled toilet design suggests doors that open outwards to facilitate access if someone falls behind the door. Whilst photographic images produced at Inquest suggested adequate door clearance for a resident sitting normally on the toilet, that would not be so for an individual resident who sat / was slumped forward.
” Open source report
×
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 Building Control should advise on toilet door opening direction matters.
Verbatim wording from the response “We note your comment relating to toilet doors opening outwards. It seems to us that it would not be appropriate for the CQC to provide any expert comment in this area. We respectfully suggest that it would be more appropriate for the Building Control department of the Bury Metropolitan Borough Council to advise on such matters. We are mindful on the one hand that a door opening outwards into a corridor might reduce the risk of a person using the toilet striking their head against an opened door while increasing accessibility in the event of a fall. On the other hand, we also recognise that outward-opening doors may pose inherent risks to passers-by outside a toilet and especially so where a service is frequented by people who may have a visual impairment or mobility problems.” Source location 2015-0047-Response-by-Care-Quality-Commission
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 Providing expert advice on toilet door opening direction is outside the CQC’s appropriate role.
Verbatim wording from the response “We note your comment relating to toilet doors opening outwards. It seems to us that it would not be appropriate for the CQC to provide any expert comment in this area. We respectfully suggest that it would be more appropriate for the Building Control department of the Bury Metropolitan Borough Council to advise on such matters. We are mindful on the one hand that a door opening outwards into a corridor might reduce the risk of a person using the toilet striking their head against an opened door while increasing accessibility in the event of a fall. On the other hand, we also recognise that outward-opening doors may pose inherent risks to passers-by outside a toilet and especially so where a service is frequented by people who may have a visual impairment or mobility problems.” Source location 2015-0047-Response-by-Care-Quality-Commission
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 service provider is responsible for managing risks arising from the toilet door mechanism it implements.
Verbatim wording from the response “It is the responsibility of the service provider to manage the risks posed by whichever mechanism it implements to ensure the welfare and safety of service users.” Source location 2015-0047-Response-by-Care-Quality-Commission
Open published response
5 Feb 2015 Mr Ward · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Failure of care staff to recognise the increased bleeding risk for patients on warfarin after a head injury View source Lack of clear policy or training for dealing with patients on anticoagulant therapy View source Lack of a clear procedure for escalation and referral after a patient fall 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
Mr Ward · 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
Mr Ward, an 85-year-old care home resident taking warfarin, suffered an unwitnessed fall and head injury on 29 November 2014. He was found unresponsive the following morning and died on 11 December 2014 after a CT confirmed a subdural haematoma. Concerns included staff awareness of the increased bleeding risk associated with head injury while taking warfarin, and the lack of clear policy, training, and escalation procedures for such 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 Care Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of care staff to recognise the increased bleeding risk for patients on warfarin after a head injury
Wider context from the report “(1) Mr Ward was an elderly patient who was at risk of falling and who was on long term warfarin. There is an increased risk of bleeding to elderly patients on warfarin who sustain a head injury. The care staff who attended to Mr Ward appeared to be unaware of the increased risk of bleeding even though there weren’t visible injuries.
(2) During the inquest evidence was given in relation to the fall risk assessment and the policy adopted. However, there was no clear policy or training highlighted in dealing with patients who are on anti-coagulant therapy. In addition, it wasn’t clear the procedure for the escalation and referral of patients to qualified medical staff in the event of a fall.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of clear policy or training for dealing with patients on anticoagulant therapy
Wider context from the report “(1) Mr Ward was an elderly patient who was at risk of falling and who was on long term warfarin. There is an increased risk of bleeding to elderly patients on warfarin who sustain a head injury. The care staff who attended to Mr Ward appeared to be unaware of the increased risk of bleeding even though there weren’t visible injuries.
(2) During the inquest evidence was given in relation to the fall risk assessment and the policy adopted. However, there was no clear policy or training highlighted in dealing with patients who are on anti-coagulant therapy . In addition, it wasn’t clear the procedure for the escalation and referral of patients to qualified medical staff in the event of a fall.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear procedure for escalation and referral after a patient fall
Wider context from the report “(1) Mr Ward was an elderly patient who was at risk of falling and who was on long term warfarin. There is an increased risk of bleeding to elderly patients on warfarin who sustain a head injury. The care staff who attended to Mr Ward appeared to be unaware of the increased risk of bleeding even though there weren’t visible injuries.
(2) During the inquest evidence was given in relation to the fall risk assessment and the policy adopted. However, there was no clear policy or training highlighted in dealing with patients who are on anti-coagulant therapy. In addition, it wasn’t clear the procedure for the escalation and referral of patients to qualified medical staff in the event of a fall .
” Open source report
Concerns raised 9 Failure to periodically review and revise staff training View source Failure to provide formalised, regular and personalised training on establishment practices and protocols View source Failure to accurately record incidents affecting residents’ care and management View source Failure to reinforce effective record keeping through regular management file checks View source Failure to prioritise assistance with improving care-note recording View source Failure to regularly evaluate care-note quality and communicate shortcomings to staff View source Unauthorised medication or prescription of ineffective remedies by non-medically qualified care staff View source Unauthorised speculation by non-medically qualified care staff about possible causes of symptoms View source Lack of a clear directive for care staff to seek medical advice without delay for residents presenting with pain View source See 6 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.
×
AI-generated summary
EDWIN THOMPSON · 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
Edwin Thompson, a 77-year-old residential care home resident with dementia, was found dead in a bathroom on 8 October 2011. The post-mortem identified a previously undiagnosed cardiovascular disease as the natural cause of death. The report identified concerns about protective measures for a vulnerable resident, delayed medical assistance, loss of contact with a resident prone to wandering, response to a final medical crisis, staff training, and record keeping.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to periodically review and revise staff training
Wider context from the report “Training in the practices and protocols within the establishment should be formalised, regularised and directed as a personalised package to all staff. It should be the subject of planned periodic review and revision throughout the year and an integral part of the established annual appraisal of staff members and their performance.
The quality and effectiveness of in house training provision should be an integral and essential element in and of the periodic appraisal of management performance.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formalised, regular and personalised training on establishment practices and protocols
Wider context from the report “Training in the practices and protocols within the establishment should be formalised, regularised and directed as a personalised package to all staff. It should be the subject of planned periodic review and revision throughout the year and an integral part of the established annual appraisal of staff members and their performance.
The quality and effectiveness of in house training provision should be an integral and essential element in and of the periodic appraisal of management performance.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record incidents affecting residents’ care and management
Wider context from the report “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents.
The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard.
Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to reinforce effective record keeping through regular management file checks
Wider context from the report “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents.
The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard.
Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to prioritise assistance with improving care-note recording
Wider context from the report “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents.
The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard.
Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to regularly evaluate care-note quality and communicate shortcomings to staff
Wider context from the report “The accurate recording of incidents affecting the care and management of residents is an essential tool in keeping staff informed of the needs of residents in order that the staff can be better able to react respond and plan for the essential needs of residents.
The quality of the recording of notes must be evaluated by management on their regular reviews of residents care notes and staff must be made aware in a timely fashion of any shortcomings in the notes and their content. Assistance to improve in the recording of notes must be given an urgent priority in any training needs and recognised as a significant performance issue if there is consistent failure to adhere to the expected standard.
Ultimately and aspirationally a computer based system of record keeping would be the preferred option, but the lesson of effective record keeping in whatever format, has to be reinforced by regular and effective file checks by Managers.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unauthorised medication or prescription of ineffective remedies by non-medically qualified care staff
Wider context from the report “There is a need to draft and disseminate to all care staff a clear, simple and concise directive to care home staff to seek medical advice or assistance in respect of residents presenting with pain, particularly of a cardiac nature without delay.
Staff with no medical qualification must not seek to speculate as to possible causes of symptoms and should not seek to medicate ( unless otherwise previously prescribed by a Medical Practitioner) or prescribe “remedies” of no or no known worth to anyone in their care.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Unauthorised speculation by non-medically qualified care staff about possible causes of symptoms
Wider context from the report “There is a need to draft and disseminate to all care staff a clear, simple and concise directive to care home staff to seek medical advice or assistance in respect of residents presenting with pain, particularly of a cardiac nature without delay.
Staff with no medical qualification must not seek to speculate as to possible causes of symptoms and should not seek to medicate ( unless otherwise previously prescribed by a Medical Practitioner) or prescribe “remedies” of no or no known worth to anyone in their care.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear directive for care staff to seek medical advice without delay for residents presenting with pain
Wider context from the report “There is a need to draft and disseminate to all care staff a clear, simple and concise directive to care home staff to seek medical advice or assistance in respect of residents presenting with pain, particularly of a cardiac nature without delay.
Staff with no medical qualification must not seek to speculate as to possible causes of symptoms and should not seek to medicate ( unless otherwise previously prescribed by a Medical Practitioner) or prescribe “remedies” of no or no known worth to anyone in their care.
” Open source report
24 Oct 2014 Hilda May Cole · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 1 Failure to inform service users about additional alarm facilities 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
Hilda May Cole · 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
Hilda May Cole, aged 86, was found dead at home on 7 July 2014 after dying from burns, probably caused by a lit cigarette dropped onto a sofa or material on it. The concern was that her pendant alarm system could have been linked to a fire alarm, but her family were unaware of this facility and had not subscribed to it; the report questioned whether existing and new customers were adequately informed.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to inform service users about additional alarm facilities
Wider context from the report “1. Mrs Cole had one of the pendant alarms supplied by you. She was a smoker with reduced mobility and there was a risk of fires. At the inquest I heard that family members were not aware that the system that you provide can be linked into other alarms such as fire alarms and burglar alarms . If they had been aware they would have subscribed to the fire alarm system for Mrs Cole. The family have told me that they have subsequently seen literature on which these others services do appear. However they wonder if you should be taking more steps to advise existing service users of the additional facilities you provide and if new customers are aware of these facilities . I wonder if this something that you should be pursuing?
” Open source report
Concerns raised 2 Failure of food provision and presentation procedures to accommodate residents requiring modified food preparation and assistance View source Lack of appropriate ongoing professional development training for nursing staff 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
Dorothy Mavis Clarkson · 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
Dorothy Mavis Clarkson choked on a large piece of meat while eating at Longton Nursing and Residential Home on 25 July 2013, became unresponsive, and died in hospital on 27 July 2013. The substantive concerns related to how food was provided and presented to residents requiring modified food or assistance, and to appropriate ongoing professional training for nursing staff.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure of food provision and presentation procedures to accommodate residents requiring modified food preparation and assistance
Wider context from the report “(1) the procedure by which food is provided and presented to residents who require food to be prepared in a certain way and who need assistance by virtue of their physical or mental condition ;
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of appropriate ongoing professional development training for nursing staff
Wider context from the report “(2) a lack of training appropriate to nursing staff working in a nursing home being undertaken by qualified nursing staff to satisfy the on-going professional development requirement of the Nursing and Midwifery Council .
” Open source report
12 Sep 2014 Barbara Monica May Cooke · Prevention of Future Deaths report Isle of Wight
View report summary
Concerns raised 6 Lack of a protocol for chasing up unresponded District Nurse Service messages View source Failure to recognise infection risks from leaving incontinent residents in their own waste View source Inadequate staffing levels for meeting residents’ care, medication, comfort and dignity needs View source Lack of admission recording of open safeguarding concerns View source Lack of automatic coroner referral for deaths of inpatients subject to safeguarding alerts View source Lack of automatic safeguarding-team notification of deaths of inpatients subject to open safeguarding alerts 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.
×
AI-generated summary
Barbara Monica May Cooke · 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 Monica May Cooke, an 84-year-old resident of Waxham House Residential Care Home, developed severe pressure ulcers, sepsis and multiple organ failure, and died in hospital on 11 April 2014. The report raised concerns about inadequate staffing, delays in toileting and cleaning, failure to recognise and manage infection risks associated with pressure sores, and gaps in communication and safeguarding procedures after her admission and death.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for chasing up unresponded District Nurse Service messages
Wider context from the report “3. I am concerned that there appears to be no protocol at Waxham House to chase up the District Nurse Service if they haven’t responded to a message within 24
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise infection risks from leaving incontinent residents in their own waste
Wider context from the report “2. I am concerned that the Waxham House Residential Care Home didn’t recognise the obvious risks of infection of leaving an incontinent lady sitting in her own waste when she was prone to sacral sores , and almost certainly had at least one at the point at which she was left sitting in her own urine and excrement for two and half hours on 30th March 2014.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels for meeting residents’ care, medication, comfort and dignity needs
Wider context from the report “1. During the course of the evidence, it became clear that the resident to staff ratio of 20:2 during between 2 p.m. and 9 p.m. was inadequate to deal with all the residents’ needs at Waxham House. (The staffing levels at other times also appeared inadequate for the numbers of residents .) The staffing levels did not allow for one staff member to safely distribute medication to the residents without interruption ; provide teas for the residents and cater for their other reasonable needs in an acceptable timeframe. I was concerned that residents were being left for two and a half hours, sitting in their own excrement, waiting to be taken to the toilet and cleaned, and that there were insufficient staff to attend to a resident who was clearly dying . Moreover, I am concerned that there were insufficient staff members to escort residents away from a resident who was being attended to by paramedics , thereby denying this lady any dignity in her last moments.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of admission recording of open safeguarding concerns
Wider context from the report “4. I am concerned that there does not appear to be a system in place at St Mary’s Hospital to record on admission that a patient is the subject of an open Safeguarding concern . (In this case, the subject of the Safeguarding alert was an adult, but this concern relates to both adults and children.)
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic coroner referral for deaths of inpatients subject to safeguarding alerts
Wider context from the report “5. I am further concerned that there is currently no system in place at St Mary’s Hospital to automatically contact the Coroner to refer the matter for investigation when a person who is the subject of a Safeguarding alert dies whilst an inpatient in the Hospital .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic safeguarding-team notification of deaths of inpatients subject to open safeguarding alerts
Wider context from the report “6. I am concerned that there is currently no system in place at St Mary’s Hospital to automatically notify the IOW Safeguarding Team if someone who is the subject of an open safeguarding alert dies whilst an inpatient in the Hospital .
” Open source report
10 Sep 2014 JAMES DWAYNE CLARKE · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Failure to carry out required overnight checks View source Lack of clear instructions defining required overnight checks View source Lack of practical training for carers View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
JAMES DWAYNE CLARKE · 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
James Dwayne Clarke was involved in a motorcycle collision, became paraplegic and had a tracheotomy tube. After he was discharged home, carers failed to check him during parts of the night and did not notice that his tracheotomy tube had become blocked, resulting in his death. The principal concerns were that the standard of care was seriously lacking and that the carers had received theoretical but no practical training, potentially placing others receiving services at risk.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out required overnight checks
Wider context from the report “My concerns are that two carers having been employed, the expectation was that one would be with James constantly. The written instructions from the care home said “Call is to check James throughout the night and carry out tracheotomy care/suction if necessary”. Whilst there was no further explanation of what “throughout the night” meant, the evidence I had was that the carers sat in a room on the other side of the corridor to James’ bedroom, they were watching television and playing computer games and talking, they did not check him between 1.a.m and 4.a.m. and again did not check him between 4.10 a.m and 6.a.m. and only then because his peg feed alarm sounded. He was found dead at that stage. The carers had had theoretical training, but no practical training had been given to them by the care company who employed them. Their employers were Complete Care Services, which is the trading name of C.C.S. Central Limited of West Midlands House, Gypsy Lane, Willenhall, Wolverhampton, West Midlands WV13 2HA and I was told that the company are registered with the Care Quality Commission. I was concerned that the standard of care provided for James was seriously lacking and that if that standard of care was reflected in the care given to others, to whom C.C.S. provided services, then there may be a risk to other members of the public.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of clear instructions defining required overnight checks
Wider context from the report “My concerns are that two carers having been employed, the expectation was that one would be with James constantly. The written instructions from the care home said “Call is to check James throughout the night and carry out tracheotomy care/suction if necessary”. Whilst there was no further explanation of what “throughout the night” meant , the evidence I had was that the carers sat in a room on the other side of the corridor to James’ bedroom, they were watching television and playing computer games and talking, they did not check him between 1.a.m and 4.a.m. and again did not check him between 4.10 a.m and 6.a.m. and only then because his peg feed alarm sounded. He was found dead at that stage. The carers had had theoretical training, but no practical training had been given to them by the care company who employed them. Their employers were Complete Care Services, which is the trading name of C.C.S. Central Limited of West Midlands House, Gypsy Lane, Willenhall, Wolverhampton, West Midlands WV13 2HA and I was told that the company are registered with the Care Quality Commission. I was concerned that the standard of care provided for James was seriously lacking and that if that standard of care was reflected in the care given to others, to whom C.C.S. provided services, then there may be a risk to other members of the public.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of practical training for carers
Wider context from the report “My concerns are that two carers having been employed, the expectation was that one would be with James constantly. The written instructions from the care home said “Call is to check James throughout the night and carry out tracheotomy care/suction if necessary”. Whilst there was no further explanation of what “throughout the night” meant, the evidence I had was that the carers sat in a room on the other side of the corridor to James’ bedroom, they were watching television and playing computer games and talking, they did not check him between 1.a.m and 4.a.m. and again did not check him between 4.10 a.m and 6.a.m. and only then because his peg feed alarm sounded. He was found dead at that stage. The carers had had theoretical training, but no practical training had been given to them by the care company who employed them. Their employers were Complete Care Services, which is the trading name of C.C.S. Central Limited of West Midlands House, Gypsy Lane, Willenhall, Wolverhampton, West Midlands WV13 2HA and I was told that the company are registered with the Care Quality Commission. I was concerned that the standard of care provided for James was seriously lacking and that if that standard of care was reflected in the care given to others, to whom C.C.S. provided services, then there may be a risk to other members of the public.
” 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 Ensure the coroner’s report is noted and informs the provider’s next ratings inspection, including examination of processes and training.
Verbatim wording from the response “We will ensure that your report is noted and informs the next ratings inspection that takes place of Complete Care Services; although the information is now a little dated the issues are well worth a further examination of their processes and training provision.” Source location 2014-0398-Response-by-Care-Quality-Commission
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 Adopt the Health and Social Care Act 2008 fundamental standards, including requirements concerning personalised, safe and competent care.
Verbatim wording from the response “In April 2015 CQC will adopt the Health and Social Care Act 2008 (Regulated Activities) Regulations 2014, known as the “fundamental standards”. The changes in the regulations have emerged from the Robert Francis recommendations that there should be very obvious standards below which care must not fall. Regulation 9 will ensure that people receive care and treatment that is personalised for them and meets their needs; Regulation 12 is intended to prevent people from receiving unsafe care and treatment, and prevent avoidable harm or risk of harm. These regulations in particular will require providers to ensure that care is planned and delivered in a way that makes it crystal clear to care staff what is required of them, and that staff are experienced, trained and competent in the areas where they are providing that care.” Source location 2014-0398-Response-by-Care-Quality-Commission
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 Develop inspection processes using longer team-based inspections, consistent key lines of enquiry and service ratings.
Verbatim wording from the response “In implementing the new fundamental standards, our inspection processes have been developed. We will conduct longer, more in-depth inspections with a team approach designed to “get under the skin” of care services. We have key lines of enquiry which are explored and reported on consistently. Each care service will be rated either Outstanding, Good, Requires Improvement or Inadequate. We will continue to use our enforcement powers where services do not deliver safe services.” Source location 2014-0398-Response-by-Care-Quality-Commission
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 Carry out an unannounced responsive inspection of the care provider against safeguarding, risk, welfare and complaints requirements.
Verbatim wording from the response “In terms of actions that we have undertaken, in May 2011 we carried out a responsive inspection unannounced. This was the service’s first inspection under the Health and Social Care Act 2008. This would have focused on the issues considered relevant at the point of inspection and any information of concern that we held. We inspected against four of the Health and Social Care Act 2008 (Regulated Activities) Regulations 2010. These were:” Source location 2014-0398-Response-by-Care-Quality-Commission
Open published response
17 Jul 2014 Joshua Lewis BROWN · Prevention of Future Deaths report North East Kent
View report summary
Concerns raised 3 Failure to inform family members about available support information and support for themselves View source Failure to engage family members in support when information sharing is declined View source Failure to verify the accuracy and interpretation of information recorded from family members 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
Joshua Lewis BROWN · 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
Joshua Lewis BROWN died on 13 June 2011 after climbing over railings at the edge of cliffs at Louisa Bay and dropping forward from the cliff. The report identified concerns about limited information-sharing and engagement between the Community Health Team and Mr Brown’s family, including the absence of a process for family members to check the accuracy of information recorded about them. It also noted that the family was not made aware of available support and information about how best to support Mr Brown and themselves.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family members about available support information and support for themselves
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members.
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to engage family members in support when information sharing is declined
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared . They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members, with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members.
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to verify the accuracy and interpretation of information recorded from family members
Wider context from the report “(1) The evidence was that Mr Brown lived with his parents who were therefore his primary support outside the Community Health Team but were not strictly speaking his carers and therefore were not formally able to be involved as such by the Community Team when Mr Brown did not wish information about him to be shared. They therefore did not receive information that might have alerted them to periods when he was particularly vulnerable and when they might have had information that would have been of assistance to the Team in caring for Mr Brown.
(2) The evidence also demonstrated that it was not the practice of the Team to show family members what notes had been made by the Team of information shared with them by family members , with the consequence that inaccuracies or misunderstandings may have arisen in some notes, and there was no provision for those notes to be signed as accurate by the relevant family members .
(3) The family members were not made aware of ways in which they could obtain through the Kent and Medway NHS Social Care and Partnership Trust (of which the Team was a part) more information about how they might best support Mr Brown and themselves receive support.
(4) In general, the evidence showed limitations on the possibilities for engagement by the Team with family members and by family members with the Team, particularly when Mr Brown did not wish information about him to be shared and this worked to his disadvantage. There was, however, evidence of some improvement having already been made by the Trust in this respect. When engagement was possible, the absence of a system whereby a person giving information to the Team would check that that information had been correctly noted and interpreted by the Team posed obvious risks for anyone under the care of the Team.
” Open source report
Concerns raised 5 Window restraint locks being easily defeated with scissors View source Lack of proper systems for restricting access to window restraint keys View source Failure to ensure that CQC inspectors are properly aware of relevant Department of Health alerts View source Window restraints appearing secure despite not being locked View source Lack of a system for passing on CQC knowledge of misleading window restraint lock conditions View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Miss Lucy Moffatt · 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
Miss Lucy Moffatt, who was experiencing an acute phase of paranoid schizophrenia, fell or jumped from the second-floor window of her room at a Crisis House in Sheffield after being admitted on 9 July 2013. The report raised concerns that the window restraint could appear secure without being locked, could be defeated with scissors, and was not supported by sufficiently robust monitoring and key-control systems. It also identified concerns about CQC inspectors not being made properly aware of relevant Department of Health guidance and information about the restraint’s limitations.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Window restraint locks being easily defeated with scissors
Wider context from the report “(2) The lock on the window restraint could easily be defeated with a pair of scissors and this may be the case on many similar devices .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of proper systems for restricting access to window restraint keys
Wider context from the report “(3) Although the provider in question has now taken appropriate action, it may well be that many other such establishments have no proper system of window restraint key restriction .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that CQC inspectors are properly aware of relevant Department of Health alerts
Wider context from the report “(4) The CQC Inspectors had not apparently been made properly aware of the Dept of Health Alert on a matter that they were expected to check .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Window restraints appearing secure despite not being locked
Wider context from the report “(1) That the type of window restraint in question can appear secure to a 'pulling and tugging' check when it is not actually locked . This can mislead those unaware of the issue .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for passing on CQC knowledge of misleading window restraint lock conditions
Wider context from the report “(5) There is no system to ensure that CQC knowledge of a potentially misleading situation with the window restraint lock was passed on , albeit in the belief that the restraint would be locked and that residents would be low risk.
” 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 Undertake a detailed review to ensure Regulation 28 reports and other information systematically feed into intelligence monitoring, inspection and registration processes.
Verbatim wording from the response “We greatly value the intelligence provided by your report and have endeavoured to address the concerns raised within it. The CQC is currently undertaking a detailed review designed to ensure that the valuable information provided by Regulation 28 reports, as well as from other sources of information, systematically and effectively feeds into our intelligence monitoring, inspection and registration processes.” Source location 2014-0261-Response-by-Care-Quality-Commission
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 Pilot pre-inspection methodology that assesses providers’ safety-alert policies, procedures and implementation of selected alerts.
Verbatim wording from the response “6. The CQC is also testing some pre-inspection methodology to provide additional intelligence to inspectors as part of inspection pre-planning and prior to going on site during the course of an inspection. We are currently piloting some pre-inspection where we will be testing the dissemination of safety alerts by assessing provider’s policies and procedures around alerts, and the implementation of a sample of alerts selected on the basis of low compliance rates on the CAS, or intelligence that alerts have not been well implemented. By way of illustration we enclose the question/prompts that are being proposed for inspectors to look for in the provider’s policy and procedures documentation, as well as the things to look for during inspection.” Source location 2014-0261-Response-by-Care-Quality-Commission
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 Providers, rather than the regulator, must determine the systems and equipment needed to address window restraint risks.
Verbatim wording from the response “Under Regulation 16 of the Regulated Activities Regulations, the registered person, that is Sheffield Crisis in this case, must make suitable arrangements to protect service users and others who may be at risk from the use of unsafe equipment by ensuring that equipment provided for the purposes of carrying out the regulated activity is properly maintained and suitable for its purpose, and used correctly. How this regulation is complied with will be taken into account by the CQC at registration and subsequent reviews of compliance. However, at this stage the CQC does not mandate exactly what systems or equipment systems should be in place while the burden falls on the provider to ensure that they take account of Alerts such as HTM 55 in devising the particular window restrictor or that is used.” Source location 2014-0261-Response-by-Care-Quality-Commission
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 Primary responsibility for managing patient safety and implementing safety alerts rests with health and social care providers.
Verbatim wording from the response “In accordance with the evidence that was given at the inquest neither the registration assessor nor the compliance inspector in this case were specifically aware of the Department of Health Alert concerning the strength of window restraints referred to in Health Technical Memorandum (HTM) 55. The reason for this lies in the regulatory framework in which health and social care providers are registered to operate, and in accordance with the current registration and inspection CQC methodology. Under the current statutory and regulatory framework the primary responsibility for managing patient safety, and ensuring that such alerts are actioned, lies with the provider of health and social care providers.” Source location 2014-0261-Response-by-Care-Quality-Commission
Open published response
6 Jun 2014 James Edward Boylan · Prevention of Future Deaths report South and East Cumbria
View report summary
Concerns raised 6 Failure to remove removable bathroom rails except when required View source Failure to disseminate GRIST assessment information to staff View source Failure to rigorously complete GRIST assessments View source Failure to keep ligature-capable cords centrally so that patients cannot directly access them View source Failure to maintain an overall view of escalating patient risk View source Insufficient searching of patients’ property for concealed dangerous items 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
James Edward Boylan · 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
James Edward Boylan, who had a history of anxiety and was admitted to a mental health unit, died by hanging using a phone charger cord and a bathroom rail. The concerns included removable bathroom rails creating a ligature point, insufficient searching of patients’ property, access to a cord, and failures in recognising and communicating the escalation of his condition.
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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to remove removable bathroom rails except when required
Wider context from the report “(1) Removable rails in a bathroom designed for use by disabled people had been left inadvertently ever since the unit was opened. No one seemed to be aware that these rails were removable and certainly nobody had removed them. This provided a ligature point which would otherwise have been absent in a unit which was specifically designed to have as few ligature points as possible. The Coroner is concerned that this same situation may apply in other units and people need to be aware that ligature points in mental health units should be limited as far as humanly possible, and specifically that removable rails should be removed except when actually required .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to disseminate GRIST assessment information to staff
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents , because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to rigorously complete GRIST assessments
Wider context from the report “(4) GRIST: Assessments should be more rigorously completed and disseminated so that staff are aware of their contents, because in relation to Mr Boylan this did not appear to have taken place so that an opportunity for communication of information was lost.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to keep ligature-capable cords centrally so that patients cannot directly access them
Wider context from the report “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion , and so again Mr Boylan had access to something which he could use to hang himself with .
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain an overall view of escalating patient risk
Wider context from the report “(3) There were numerous events over the 7 days during which Mr Boylan was present on the ward for someone with an overall view to realise that his condition was escalating and that he might become a danger to himself, but because no one person had such knowledge of all the facts, this was not recognised . It is suggested that communication be improved in any way in which the Trust thinks possible.
” 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 Quality Commission; that does not assign responsibility.
PFD Monitor interpretation Insufficient searching of patients’ property for concealed dangerous items
Wider context from the report “(2) Mr Boylan appears to have brought onto the ward a stanley knife blade. This was not discovered for several days. Mr Boylan only left the unit on one occasion and so could only have brought the blade onto the unit either 7 days before his death or 3 days before his death. The Coroner asks that thought be given to more robust searching of patients’ property. The origin of the cord which Mr Boylan used is not clear. It may have been his own, but the policy of having these kept centrally so that patients do not have access direct to them was not adhered to on this occasion, and so again Mr Boylan had access to something which he could use to hang himself with.
” 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