Recipient

Castlehill Specialist Care Centre

First report 10 Feb 2021•Latest report 10 Feb 2021

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 5
Stated actions: 7

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

100%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Castlehill Specialist Care Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

10 Feb2021
Black Country
Concerns raised10
1. Failure to provide timely out-of-hours access to the care home for ambulances
2. Failure to follow the policy requiring 999 calls after falls involving head injury
3. Inaccurate recording of falls on monthly accidents and incidents forms
1. Delays in contacting emergency ambulance services after a fall
2. Failure to complete required referral to the physiotherapy team
3. Failure to follow the policy requiring 999 calls after falls involving head injury
4. Failure to identify and address patterns of falls and increasing risk
5. Delays in notifying senior management after a fall
6. Failure to update falls risk assessments and care plans after every fall
7. Failure to update falls risk assessments and care plans after every fall
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Continue raising safeguarding alerts after falls.
  Stated completed
2. Action
  Continue making 111/999 calls after falls and call 999 whenever a resident prescribed Apixaban falls.
  Stated completed
3. Action
  Install corridor monitoring screens linked to the external doorbell with audible alerts to improve timely building access.
  Stated completed
1. Action
  Request one-to-one funding where appropriate to maintain resident safety during further assessments.
  Stated planned
2. Action
  Hold weekly ward rounds with the GP and senior nursing team to discuss information and multidisciplinary referrals and make appropriate referrals.
  Stated completed
Respondent positions 1
1. Position
  Declined one-to-one funding can prevent maintaining enhanced supervision while further resident safety assessments are undertaken.
  Unable to act
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.

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 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
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
Page 1 · response
Published 4 May 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Continue 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
Page 1 · response
Published 4 May 2021
Open published response
Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
Install 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
Page 1 · response
Published 4 May 2021
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
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
Page 1 · response
Published 4 May 2021
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
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
Page 1 · response
Published 4 May 2021
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
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
Page 1 · response
Published 4 May 2021
Open published response

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised10

Failure to provide timely out-of-hours access to the care home for ambulances

Failure to follow the policy requiring 999 calls after falls involving head injury

Inaccurate recording of falls on monthly accidents and incidents forms

Delays in contacting emergency ambulance services after a fall

Failure to complete required referral to the physiotherapy team

Failure to follow the policy requiring 999 calls after falls involving head injury

Failure to identify and address patterns of falls and increasing risk

Delays in notifying senior management after a fall

Failure to update falls risk assessments and care plans after every fall

Failure to update falls risk assessments and care plans after every fall

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

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.1

Actions described in response 5

Respondent positions 1