Recipient

Chilton Care Centre

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First report 20 Sep 2019•Latest report 20 Sep 2019

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. County Durham and Darlington

    AI-generated summary

    Robert Edward LOWE · 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

    Robert Edward LOWE suffered an unwitnessed fall from his bed at Chilton Care Centre on 13 May 2019 and lay undetected for up to two hours. Concerns were raised that pressure mats could be bypassed and that competing audible alarms might prevent important alerts from reaching 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 Chilton Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of pressure mats to prevent residents bypassing bed-exit detection

    Wider context from the report

    “A) Circumstances at Chilton Care Centre are such that the placing of pressure mats (intended to detect residents leaving their beds unaided) is such that residents may bypass those mats; B) The use and operation of audible signals is such that important audible alarms may not come to the attention of staff. Mr LOWE left his bed and fell unwitnessed and then lay undetected by his bed for up to two hours until a scheduled welfare check. The pressure mat may not have been triggered. The basis for my concern is as follows: (A) ████████, Chilton Home Manager said that when she investigated this matter (by which time the mat had been removed) "...there could have been a possibility that Mr LOWE, may have bypassed the mat when getting out at the top of his bed..."(witness statement dated 11th August 2019); and (B) In the same statement, ████████ stated: "Then... when staff carried out another welfare check, they found Mr Lowe on the floor. Three out of 4 staff on duty and only one believes that the mat had not activated and the other 3 could not remember if the sensor mat was making a sound or not, as the emergency buzzer was pressed and other buzzers around the home were also going at the same time, and their priority was Mr Lowe..." ”
    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 Chilton Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of audible alarm signals to come to staff attention

    Wider context from the report

    “A) Circumstances at Chilton Care Centre are such that the placing of pressure mats (intended to detect residents leaving their beds unaided) is such that residents may bypass those mats; B) The use and operation of audible signals is such that important audible alarms may not come to the attention of staff. Mr LOWE left his bed and fell unwitnessed and then lay undetected by his bed for up to two hours until a scheduled welfare check. The pressure mat may not have been triggered. The basis for my concern is as follows: (A) ████████, Chilton Home Manager said that when she investigated this matter (by which time the mat had been removed) "...there could have been a possibility that Mr LOWE, may have bypassed the mat when getting out at the top of his bed..."(witness statement dated 11th August 2019); and (B) In the same statement, ████████ stated: "Then... when staff carried out another welfare check, they found Mr Lowe on the floor. Three out of 4 staff on duty and only one believes that the mat had not activated and the other 3 could not remember if the sensor mat was making a sound or not, as the emergency buzzer was pressed and other buzzers around the home were also going at the same time, and their priority was Mr Lowe..." ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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