10 Feb 2021 Eric Harold Bird · Prevention of Future Deaths report Black Country
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Concerns raised 10 Failure to provide timely out-of-hours access to the care home for ambulances View source Failure to follow the policy requiring 999 calls after falls involving head injury View source Inaccurate recording of falls on monthly accidents and incidents forms View source Delays in contacting emergency ambulance services after a fall View source Failure to complete required referral to the physiotherapy team View source Failure to follow the policy requiring 999 calls after falls involving head injury View source Failure to identify and address patterns of falls and increasing risk View source Delays in notifying senior management after a fall View source Failure to update falls risk assessments and care plans after every fall View source Failure to update falls risk assessments and care plans after every fall View source See 7 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Continue raising safeguarding alerts after falls.
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Action
Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
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Action
Install corridor monitoring screens linked to the external doorbell with audible alerts to improve timely building access.
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Action
Request one-to-one funding where appropriate to maintain resident safety during further assessments.
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Action
Hold weekly ward rounds with the GP and senior nursing team to discuss information and multidisciplinary referrals and make appropriate referrals.
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AI-generated summary
Eric Harold Bird · 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
Eric Harold Bird, a 91-year-old man with dementia and assessed as being at high risk of falls, suffered seven falls during a four-week period in a specialist care centre. After a fall on 21/11/20, he sustained a subdural haematoma and died in hospital on 30/11/20. The principal concerns included failures to follow procedures after head injuries, delays in contacting emergency services and gaining ambulance access, and inadequate updating and review of his falls risk documentation and care plan.
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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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely out-of-hours access to the care home for ambulances
Wider context from the report “5. On arrival the ambulance was unable to gain access to the care home until 22.11 as there was no answer at the door . I heard evidence at the inquest that arrangements had now been made for a staff member to wait in the reception area when an ambulance is now called out of hours to facilitate entry;
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy requiring 999 calls after falls involving head injury
Wider context from the report “2. The inquest heard that Castlehill polices had not been followed after each fall whereby Mr Bird hit his head . Mr Bird was taking apixaban which meant he was at a higher risk of bleeding. Evidence was heard that policy required 999 to be called . This was not done on 1/11/20 nor on 14/11/20 .
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of falls on monthly accidents and incidents forms
Wider context from the report “9. There were discrepancies in the recording of the falls on the monthly accidents and incidents form and no evidence that any consideration had been given to a pattern of falls which needed to be addressed to reduce Mr Bird’s apparent increasing risks.
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Delays in contacting emergency ambulance services after a fall
Wider context from the report “4. On 21/11/20 I heard evidence that the fall occurred at approximately 20.20/20.30 hours. Records suggested the 111 service was contacted at 21.06 . I heard evidence that it was the 111 service that made arrangements for an ambulance to attend and the EPR showed that the ambulance was contacted at 21.34 arriving on site at 21.47 ;
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to complete required referral to the physiotherapy team
Wider context from the report “1. After Mr Bird’s admission and initial falls risk assessment, there was a reference that Mr Bird needed to be referred to the physio team but no evidence this was actually done ;
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the policy requiring 999 calls after falls involving head injury
Wider context from the report “3. On 21/11/20 the nurse on duty called 111 instead of following policy to call 999 ;
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and address patterns of falls and increasing risk
Wider context from the report “9. There were discrepancies in the recording of the falls on the monthly accidents and incidents form and no evidence that any consideration had been given to a pattern of falls which needed to be addressed to reduce Mr Bird’s apparent increasing risks .
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Delays in notifying senior management after a fall
Wider context from the report “8. I heard evidence that after the fall on 21/11/20 whereby Mr Bird was taken to hospital, that senior management who were off site were not contacted for over 2 hours after Mr Bird fell ;
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to update falls risk assessments and care plans after every fall
Wider context from the report “7. There was no evidence of any changes being made to Mr Birds falls care plan after the fall on 14/11/20 and no rationale recorded for not doing so ;
” 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 Castlehill Specialist Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to update falls risk assessments and care plans after every fall
Wider context from the report “6. There was no evidence that Mr Bird’s falls risk assessment and falls care plan had been updated after every fall ;
” 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 Continue raising safeguarding alerts after falls.
Verbatim wording from the response “Upon any fall we continue to raise safeguarding alerts and will request 1:1 funding to maintain the resident’s safety whilst further assessments take place where appropriate. This funding is often declined and in that eventuality we will review the suitability of the placement.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
Verbatim wording from the response “We will continue to make 111/999 calls following any fall and will call 999 whenever a resident falls who is prescribed Apixaban. This will continue despite some concern from the Local Authority that we are availing of these services too often.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Install corridor monitoring screens linked to the external doorbell with audible alerts to improve timely building access.
Verbatim wording from the response “In order to aid timely access to the building we have fitted several new monitoring screens throughout the corridors linked to the external door bell with an audible alert.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Request one-to-one funding where appropriate to maintain resident safety during further assessments.
Verbatim wording from the response “Upon any fall we continue to raise safeguarding alerts and will request 1:1 funding to maintain the resident’s safety whilst further assessments take place where appropriate. This funding is often declined and in that eventuality we will review the suitability of the placement.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold weekly ward rounds with the GP and senior nursing team to discuss information and multidisciplinary referrals and make appropriate referrals.
Verbatim wording from the response “We have a weekly ward round with the GP are our Senior nursing team where all information including multi-disciplinary referrals are discussed and appropriate referrals are made by the GP.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
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 Declined one-to-one funding can prevent maintaining enhanced supervision while further resident safety assessments are undertaken.
Verbatim wording from the response “Upon any fall we continue to raise safeguarding alerts and will request 1:1 funding to maintain the resident’s safety whilst further assessments take place where appropriate. This funding is often declined and in that eventuality we will review the suitability of the placement.” Source location 2021-0122-Response-from-Castlehill-Specialist-Care-Centre-Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations