Concerns raised 5 Failure to record preceding resident falls in resident files View source Failure to comply with court orders to supply relevant evidence View source Misleading recording of resident observation intervals View source Failure to formally review falls risk assessments and care policies after a resident death View source Failure to update residents' falls risk assessments 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.
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AI-generated summary
Raymond Alfred POWELL · 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
Raymond Alfred POWELL became increasingly frail, moved into Cole Valley Nursing Home, and suffered falls on 3 November 2020 that caused an acute subdural haematoma. He later developed an infection and seizure and died on 5 December 2020. Concerns included failures to record a preceding fall, update his falls risk assessment, accurately document observations, formally review the circumstances, and comply with court orders for evidence, creating an ongoing risk to other residents.
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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record preceding resident falls in resident files
Wider context from the report “(1) The nursing home manager confirmed that a preceding fall (most likely on 15 October) had not been recorded anywhere within Raymond's file and this was the first time she was aware of a preceding fall (Raymond's family's evidence was they were told during a visit on 15 October, and nursing home carer ████████ confirmed there was a preceding fall a few weeks earlier). The nursing home manager was unable to explain why this preceding fall had not been recorded anywhere .
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to comply with court orders to supply relevant evidence
Wider context from the report “3. The nursing home failed to comply with repeated court orders to supply relevant evidence . On 14 December the nursing home manager was ordered to supply evidence by 18 January. With no response the court order was extended on 8 February to 10 February. One day late, on 11 February, the nursing home manager supplied the witness statements but no documents . On 16 February the nursing home manager was ordered to supply the documents by 23 February. With no response the nursing home manager was served with a schedule 5 notice containing a penal notice to supply the documents by 18 March. In breach of the schedule 5 notice, on 22 March the nursing home manager supplied some but not all documents . I did not accept the reported problem with an email account as justifying the needed failure to comply with court orders for 3 months .
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Misleading recording of resident observation intervals
Wider context from the report “(3) On 3 November staff were observing Raymond every 15 minutes however they only endorsed the 30 minute boxes on his observation log meaning it was misleading .
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to formally review falls risk assessments and care policies after a resident death
Wider context from the report “1. The nursing home manager confirmed that Cole Valley Nursing Home had not conducted an internal investigation into the circumstances of Raymond's death . The rationale was "no foul play or inappropriate behaviour was suspected. Staff acted appropriately and phoned 999". I am concerned that it was not thought necessary to formally review the appropriateness of Raymond's falls risk assessment and the nursing home's policies and procedures to see what lessons could be learned to improve the safety of other residents.
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to update residents' falls risk assessments
Wider context from the report “(2) The nursing home manager in her written report to the Coroner stated that Raymond's falls risk assessment had been updated. However, the evidence revealed in fact the falls risk assessment had been created on 30 September upon Raymond's arrival, and had never been updated . Raymond's named nurse should have reviewed and updated it at the end of October with the preceding fall on 15 October being a key factor in the updated assessment. The nursing home manager was unable to explain why the named nurse did not update the falls risk assessment as expected.
” Open source report
8 Feb 2019 Jean Mary Cutler · Prevention of Future Deaths report Birmingham and Solihull
View report summary
Concerns raised 10 Risk of vulnerable residents falling out of wheelchairs View source Vulnerability of residents to falls-related harm View source Inadequate assurance of wheelchair-fall risk management View source Undated and unsigned falls risk management and assessment documents View source Failure to investigate restraint-device availability and use inside the nursing home View source Reliance on staff presence to prevent falls View source Inconsistent use of wheelchair lap belts across locations View source Inadequate post-incident investigation and organisational learning View source Inadequate completion of falls risk assessments View source Reliance on staff intervention during wheelchair falls 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
Jean Mary Cutler · 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 Mary Cutler had severe dementia, osteoporosis and no independent mobility, and was at high risk of falling. On 5 October 2018 she fell from her wheelchair at Cole Valley Nursing Home, sustaining a fractured left femur, and died there on 18 October 2018. Concerns included inconsistent use of lap belts, reliance on staff intervention despite understaffing, and inadequate post-incident investigation and falls risk assessment.
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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Risk of vulnerable residents falling out of wheelchairs
Wider context from the report “4. However, the inconsistency of using lap belts outside the nursing home, but no similar restraint device when inside remains. The reliance on a member of staff being able to intervene in time continues despite the incident on 5/10/18 revealing the inadequacy of this as a safety measure. The nursing home has not investigated the availability and use of restraint devices inside the nursing home. My on-going concern is that there remains a risk of vulnerable residents falling out of wheelchairs .
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Vulnerability of residents to falls-related harm
Wider context from the report “1. Cole Valley Nursing Home is run by a private company and cares for up to 45 residents who are vulnerable due to their age and physical and mental health issues .
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate assurance of wheelchair-fall risk management
Wider context from the report “3. I heard evidence that following the incident the Care Quality Commission and Clinical Commission Group had requested from the nursing home copies of revised risk management documents. In my opinion this has led to the nursing home being given the impression their management of residents from falling out of wheelchairs is adequate .
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Undated and unsigned falls risk management and assessment documents
Wider context from the report “6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls. My on-going concern is that the falls risk assessment has not being adequately completed.
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate restraint-device availability and use inside the nursing home
Wider context from the report “4. However, the inconsistency of using lap belts outside the nursing home, but no similar restraint device when inside remains. The reliance on a member of staff being able to intervene in time continues despite the incident on 5/10/18 revealing the inadequacy of this as a safety measure. The nursing home has not investigated the availability and use of restraint devices inside the nursing home. My on-going concern is that there remains a risk of vulnerable residents falling out of wheelchairs.
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Reliance on staff presence to prevent falls
Wider context from the report “6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls . My on-going concern is that the falls risk assessment has not being adequately completed.
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Inconsistent use of wheelchair lap belts across locations
Wider context from the report “2. Pre-incident, the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk ; Outside the nursing home a lap belt would be attached to the wheelchair. Whereas inside the nursing home no lap belt was used. A member of staff was expected to be able to intervene when a resident was in the process of falling.
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate post-incident investigation and organisational learning
Wider context from the report “5. The nursing home’s internal investigation recognised as root causes of the incident a lack of internal knowledge and guidance, that the home had been through a hard time recently and it had impacted on the staff, that care plans did not give correct guidance to staff, and that management was unstable. However, the only post-action event listed was an ‘incident debrief’. The nursing home manager agreed when given evidence that the action plan would have been more effective if it had included a review of the falls risk assessment, the viability of restraint devices being used both outside and inside, and a review of whether staff numbers were adequate. My on-going concern is that the post incident investigation was inadequate and lessons have not been learned .
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate completion of falls risk assessments
Wider context from the report “6. The current falls Risk Management and Risk Assessment documents (requested by the CQC and CCG) are undated and unsigned and continue to place reliance on the presence of a staff member to prevent falls. My on-going concern is that the falls risk assessment has not being adequately completed .
” 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 Cole Valley Care Limited; that does not assign responsibility.
PFD Monitor interpretation Reliance on staff intervention during wheelchair falls
Wider context from the report “2. Pre-incident, the risk of residents falling from a wheelchair was recognised. There was an inconsistent approach to managing this risk; Outside the nursing home a lap belt would be attached to the wheelchair. Whereas inside the nursing home no lap belt was used. A member of staff was expected to be able to intervene when a resident was in the process of falling.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations