Concerns raised 3 Care and support placement records omitting identified stair-related fall risks View source Failure to provide recommended safety equipment in the home View source Failure to escalate falls for further assessment of safe home mobility View source
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
Hold further Home First Forum events quarterly to maintain referral guidance for domiciliary care providers.
View source
Action
Reinforce escalation of concerns through appropriate referrals to professionals who can assess risks and recommend protective measures.
View source
Action
Establish the Home First Forum to inform domiciliary care providers about referral routes for concerns.
View source
Action
Follow up delays in providing recommended aids and equipment for service users.
View source
Action
Continue staff training and reinforce accurate recording of falls and other health-related events.
View source See 2 more actions
×
AI-generated summary
Jean MULLEN · 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
Jean Mullen, an 87-year-old woman, was found collapsed and unresponsive at the bottom of the stairs at home after her pendant alarm was triggered on 22 June 2024; the inquest concluded that her death was accidental, involving a fall from height, fracture of the neck and subdural haemorrhage. Concerns included the failure to provide a recommended grab rail, failure to escalate a fall in the shower or reassess her mobility and equipment needs, and incomplete recording of stair-related risks.
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 City of Doncaster Council; that does not assign responsibility.
PFD Monitor interpretation Care and support placement records omitting identified stair-related fall risks
Wider context from the report “During the course of the inquest I heard evidence regarding communications between various departments of Adult Social Care and Home First and in particular STEPS. There had been an assessment by the therapist at Doncaster Royal Infirmary regarding Mrs Mullen returning to a safe home environment and what support and equipment would be required to allow that to take place. This included an assessment in the home with social workers present. A care package was provided by STEPS and it quickly became apparent that long term care and support would be required in the home and thus an application was completed on the 12th April. Mrs Mullen's family referred to them being informed that a grab rail would be required at the top of the stairs near the bathroom to help Mrs Mullen navigate to the bathroom thus reducing the risk of falls. This was not provided.
A fall occurred when Mrs Mullen was in the shower but the carers failed to escalate this and made no referrals for any further assessment to take place in relation to Mrs Mullen's mobility and ability to continue living safely at her home address. Further this was a missed opportunity to assess whether any other aids or equipment were needed to support her. Had this taken place it is likely that the absence of the grab rail would have been identified. This was a further missed opportunity.
Finally, the care and support placement referred to in the second exhibit to ████████'s report made no reference to the issue of stairs and the risk of falling that they presented.
” 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 City of Doncaster Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide recommended safety equipment in the home
Wider context from the report “During the course of the inquest I heard evidence regarding communications between various departments of Adult Social Care and Home First and in particular STEPS. There had been an assessment by the therapist at Doncaster Royal Infirmary regarding Mrs Mullen returning to a safe home environment and what support and equipment would be required to allow that to take place. This included an assessment in the home with social workers present. A care package was provided by STEPS and it quickly became apparent that long term care and support would be required in the home and thus an application was completed on the 12th April. Mrs Mullen's family referred to them being informed that a grab rail would be required at the top of the stairs near the bathroom to help Mrs Mullen navigate to the bathroom thus reducing the risk of falls. This was not provided.
A fall occurred when Mrs Mullen was in the shower but the carers failed to escalate this and made no referrals for any further assessment to take place in relation to Mrs Mullen's mobility and ability to continue living safely at her home address. Further this was a missed opportunity to assess whether any other aids or equipment were needed to support her. Had this taken place it is likely that the absence of the grab rail would have been identified. This was a further missed opportunity.
Finally, the care and support placement referred to in the second exhibit to ████████'s report made no reference to the issue of stairs and the risk of falling that they presented.
” 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 City of Doncaster Council; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate falls for further assessment of safe home mobility
Wider context from the report “During the course of the inquest I heard evidence regarding communications between various departments of Adult Social Care and Home First and in particular STEPS. There had been an assessment by the therapist at Doncaster Royal Infirmary regarding Mrs Mullen returning to a safe home environment and what support and equipment would be required to allow that to take place. This included an assessment in the home with social workers present. A care package was provided by STEPS and it quickly became apparent that long term care and support would be required in the home and thus an application was completed on the 12th April. Mrs Mullen's family referred to them being informed that a grab rail would be required at the top of the stairs near the bathroom to help Mrs Mullen navigate to the bathroom thus reducing the risk of falls. This was not provided.
A fall occurred when Mrs Mullen was in the shower but the carers failed to escalate this and made no referrals for any further assessment to take place in relation to Mrs Mullen's mobility and ability to continue living safely at her home address . Further this was a missed opportunity to assess whether any other aids or equipment were needed to support her. Had this taken place it is likely that the absence of the grab rail would have been identified. This was a further missed opportunity.
Finally, the care and support placement referred to in the second exhibit to ████████'s report made no reference to the issue of stairs and the risk of falling that they presented.
” 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 Hold further Home First Forum events quarterly to maintain referral guidance for domiciliary care providers.
Verbatim wording from the response “Since this incident and as part of “lessons learnt” we have set up a “Home First Forum” with a view to providing all domiciliary home care providers information as to when and to whom they should direct any referrals. The first event was held on 30 January 2025 and further events will be held on a quarterly basis.” Source location Response from Doncaster Council
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 Reinforce escalation of concerns through appropriate referrals to professionals who can assess risks and recommend protective measures.
Verbatim wording from the response “➢ It should be noted that carers and social care staff are not qualified to diagnose medical conditions or to make recommendations for aids and equipment. Their role is to raise any perceived concerns and to direct the person in question to the relevant professional for advice, usually an occupational therapist, physiotherapist, or District Nurse. All staff are aware of this process and do not require permission to take such steps.” Source location Response from Doncaster Council
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 Establish the Home First Forum to inform domiciliary care providers about referral routes for concerns.
Verbatim wording from the response “Since this incident and as part of “lessons learnt” we have set up a “Home First Forum” with a view to providing all domiciliary home care providers information as to when and to whom they should direct any referrals. The first event was held on 30 January 2025 and further events will be held on a quarterly basis.” Source location Response from Doncaster Council
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 Follow up delays in providing recommended aids and equipment for service users.
Verbatim wording from the response “(2) Following up on recommendations for aids and equipment required to ensure a safe home environment for elderly persons such as Mrs Mullen: where a recommendation has been made for aids and equipment, this will be ordered by the professional making the recommendation. The Council will always follow up any delay in provision and assist in any way possible.” Source location Response from Doncaster Council
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 staff training and reinforce accurate recording of falls and other health-related events.
Verbatim wording from the response “➢ All of our social care staff undergo specific training as a matter of course on the need for detailed accurate records to be maintained in care settings, including the recording of slips and falls and general health related events.” Source location Response from Doncaster Council
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 A single fall would not ordinarily require a referral unless carers considered referral to be in the person’s best interests.
Verbatim wording from the response “As a matter of practice, a single fall event would not be expected to raise a referral. Mrs Mullen was in receipt of care specifically to assist her with showering and any concerns in this respect would have been referred by the carers from Newdon Care to RDaSH for the falls service, occupational therapy, and physiotherapy, in the event that they considered this to be in Mrs Mullen’s best interests.” Source location Response from Doncaster Council
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 Relevant professionals, rather than social care staff, must assess risks and recommend or order aids and equipment.
Verbatim wording from the response “➢ It should be noted that carers and social care staff are not qualified to diagnose medical conditions or to make recommendations for aids and equipment. Their role is to raise any perceived concerns and to direct the person in question to the relevant professional for advice, usually an occupational therapist, physiotherapist, or District Nurse. All staff are aware of this process and do not require permission to take such steps.” Source location Response from Doncaster Council
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 Council had no record that concerns about deteriorating ability on stairs were reported by family, carers or the individual.
Verbatim wording from the response “The Council does not have any record of Patricia Mullen informing social care that the stairs were becoming too much for her mother and neither was this identified as an issue by the carers. If any concern had been expressed by Patricia Mullen, and carers or Mrs Mullen herself (who had full capacity), this would have been recorded and investigated.” Source location Response from Doncaster Council
Open published response
Concerns raised 1 Lack of warning signs for slippery road conditions View source
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. 1
Action
Arrange installation of warning signs alerting road users to potentially slippery conditions.
View source
×
AI-generated summary
Ellie Jay Chappell · 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
Ellie Jay Chappell was driving on the A614 on 2 January 2017 when her vehicle struck ice, lost control and collided with an oncoming vehicle; the report states that death was confirmed at the scene. The principal concern was the absence of warning signs about slippery road conditions on a stretch with previous collisions involving slippery roads, creating a risk to future drivers.
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 City of Doncaster Council; that does not assign responsibility.
PFD Monitor interpretation Lack of warning signs for slippery road conditions
Wider context from the report “(1) Given the number of road traffic incidents on this stretch of road and the proportion which recorded the slippery road as being a factor, I am concerned that the absence of any warning signs in this vicinity will put drivers at risk of incidents and death in the future.
” 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 Arrange installation of warning signs alerting road users to potentially slippery conditions.
Verbatim wording from the response “The Council has noted your concerns regarding the absence of signs to warn of the potential for slippery road conditions. We are not aware of any previous concerns being raised by South Yorkshire Police. However, we are always willing to consider matters relating to road safety. Accordingly, in light of the concerns you have identified, I can confirm that arrangements are being made for the provision of warning signs, and it is anticipated that these will be installed by the end of September 2017.” Source location 2017-0198-Response-by-Doncaster-Borough-Council
Open published response
Concerns raised 1 Failure to apply the 40mph speed restriction prior to the bend View source
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. 1
Action
Continue assessing a proposed reduction of the relevant A630 speed limit to 40mph through the required statutory process.
View source
×
AI-generated summary
Bartosz Kacper Bortniczak and 4 others · 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 15 November 2014, a vehicle carrying Bartosz Bortniczak, Blake Cairns, Jordanna Goodwin, Arapad Kore and Megan Storey collided with an oncoming vehicle after entering a bend on the A630 at about 73 mph. All five occupants suffered fatal injuries. The report raised concern that the 60 mph speed restriction before and through the bend contributed to an ongoing risk of further deaths, given the history of incidents on that stretch of road.
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 City of Doncaster Council; that does not assign responsibility.
PFD Monitor interpretation Failure to apply the 40mph speed restriction prior to the bend
Wider context from the report “(1) The speed restriction up to and through the bend is 60mph but drops to 40mph after the bend. Given the number of incidents on this stretch of road it would appear more appropriate for the reduced speed restriction to apply prior to the bend which was the subject of these inquests. Given the number of incidents in this area, I am concern that to leave the speed restriction at sixty miles per hour leads to circumstances continuing to create a risk of other deaths occurring . In the circumstances, it is my view that the speed restriction of 40mph should be moved so that it is prior to the bend on this stretch of road.
” 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 assessing a proposed reduction of the relevant A630 speed limit to 40mph through the required statutory process.
Verbatim wording from the response “However, the Council will always consider relevant issues relating to road safety as far as it can and the concerns you have identified are in the process of being considered. In short, I can confirm that, subject to the necessary due process for such a matter, the Council intends to take steps to reduce the speed limit on the relevant stretch of road to 40mph. Any changes to the speed limit would also be complimented with additional signing and road markings as appropriate.” Source location 2015-0452-Response-by-Doncaster-Borough-Council
Open published response
Concerns raised 1 Lack of guidance for effective cleaning of fixed shower heads View source
×
AI-generated summary
Margaret Elsie 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
Margaret Elsie Clarke attended the Elements Spa in Rotherham on 14 March 2013 and later became ill, was admitted to Doncaster Royal Infirmary, and died on 27 March 2013. The inquest recorded myocardial infarction due to Legionella pneumonia, and the principal concern was the lack of guidance for effectively cleaning fixed shower heads used in leisure facilities.
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 City of Doncaster Council; that does not assign responsibility.
PFD Monitor interpretation Lack of guidance for effective cleaning of fixed shower heads
Wider context from the report “(1) There is no guidance for effective cleaning of fixed shower heads increasingly used in private and public leisure facilities.
” 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 Health and Safety Executive should review its Legionella guidance on showers and the installation and maintenance of shower systems.
Verbatim wording from the response “It would seem to me, particularly if I am correct that cleaning the showerhead alone could be ineffective, that the appropriate response to this situation would be for the HSE to review the guidance that they publish regarding Legionnaires disease to consider if greater emphasis needs to be put on showers being a suitable vector, and the required installation and maintenance of shower systems. I have copied ████████ in on this letter to allow him to comment further.” Source location 2015-0046-Response-by-Doncaster-Borough-Council
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 showerhead may not itself be unsafe; Legionella risk may arise from the whole installation and water-system management rather than component design.
Verbatim wording from the response “Secondly, I have doubts about whether it is the shower head itself that is unsafe.” Source location 2015-0046-Response-by-Doncaster-Borough-Council
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 Permanently installed showerheads are likely supplied to the plumbing trade and therefore fall outside the regulations’ remit.
Verbatim wording from the response “Firstly, there is the question of whether a shower head which requires permanent installation, rather than a detachable hose and head, is intended for consumers. It is much more likely that it is intended to be supplied to the plumbing trade and therefore outside the remit of the regulations.” Source location 2015-0046-Response-by-Doncaster-Borough-Council
Open published response
Pin
Request correction
Addressed to “Doncaster Borough Council”, a former name of City of Doncaster Council.
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations