Recipient

Daryel Care

First report 28 Mar 2025•Latest report 28 Mar 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Domiciliary care provider. 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: 2
Stated actions: 4

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

4stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

28 Mar2025
Inner North London
Concerns raised7
1. Failure to record significant post-fall injuries in care notes
2. Failure to assess reablement suitability in light of cognitive impairment and unreliable self-reporting
3. Failure to provide emergency access to the flat for carers and emergency services
1. Failure to account for cognitive, mental health and home-safety barriers when assessing engagement
2. Failure to award medical points despite evidence of unsuitable accommodation and health needs
3. Failure to escalate significant post-fall injuries for medical review
4. Inaccessible temporary accommodation for wheeled-walker use
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Update care-documentation guidance and training with structured prompts for detailed injury descriptions and recording the rationale for non-escalation after initial reporting.
  Stated planned
2. Action
  Deliver mandatory refresher training on falls, head-injury recognition, recording, and escalation protocols to all care staff.
  Stated completed
3. Action
  Enhance digital photographic injury-upload capability, obtaining explicit client consent in accordance with policy, to supplement written care-note descriptions.
  Stated planned
Respondent positions 4
1. Position
  Prior hospital assessment, existing MDT escalation, no acute red flags, and imminent care handover supported continued observation without separate immediate medical re-escalation.
  Existing arrangements considered sufficient
1. Position
  The fall and developing injury were recorded in care notes, and the head injury was escalated promptly to the multi-disciplinary team.
  Disputes the concern
2. Position
  No inappropriate “No concerns” entry attributable to staff was found in the official electronic care records, so its origin and context cannot be confirmed.
  Disputes the concern
3. Position
  Clinical oversight, including decisions about post-discharge medical review, was understood to be led by the Rapid Response team within the multi-agency framework.
  Redirects responsibility
AI-generated summary

Derrick Frederick Tully · 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

Derrick Frederick Tully was found deceased at home on 20 March 2024 after suffering a massive traumatic subdural haemorrhage, following months of falls and declining health. Concerns included unsuitable temporary accommodation, the absence of a key safe despite repeated concerns, an inappropriate reablement care package, failures to record or escalate injuries after a fall, and the discharge of Derrick from a community team without adequately factoring in his cognitive, mental health and safety difficulties.

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 Daryel Care; that does not assign responsibility.
PFD Monitor interpretation
Failure to record significant post-fall injuries in care notes
Wider context from the report
“On 20 February Derrick suffered a fall. Severe bruising and swelling developed on his face over the following days but this was not recorded in his care notes by his carers and not escalated until his daughter raised concerns on 24 February. “No concerns” was written in Derrick’s care record and no consideration given to whether he needed to be reviewed by a doctor. ”
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 Daryel Care; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess reablement suitability in light of cognitive impairment and unreliable self-reporting
Wider context from the report
“On discharge from hospital on 3 February 2024 following a fall, Derrick was provided with a good package of care. On 23 February this changed to a reablement package of care. Derrick was not suitable for reablement because of his declining cognition and progressive dementia. The occupational therapist raised concerns that he was not suitable for reablement for these reasons and because there were no rehabilitation goals. There was an over-reliance on Derrick’s self-reporting which was inaccurate given his memory problems, and a focus on him doing more for himself. He began losing weight because he was not eating, and he was not able to cope with self-care. ”
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 Daryel Care; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide emergency access to the flat for carers and emergency services
Wider context from the report
“Derrick required carers twice a day. He was also given a pendant alarm for emergencies. However, no key safe was installed meaning that even in an emergency, neither carers nor emergency services could gain entry to his flat. This was raised repeatedly by his family, carers and other professionals. ”
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 Daryel Care; that does not assign responsibility.
PFD Monitor interpretation
Failure to account for cognitive, mental health and home-safety barriers when assessing engagement
Wider context from the report
“Following MDT meetings due to concerns over Derrick’s increasing deterioration and ability to cope with his own care needs, the Integrated Community Aging Team reviewed him on 6 March. They discharged him from the service on 12 March because he did not want to engage with their home assessment of him. Derrick was suffering from cognitive impairment as a result of previous strokes and newly diagnosed dementia. He also had a mental health history and was paranoid. This was compounded by problems he’d experienced with neighbours and cuckooing concerns meaning that at times, he didn’t feel safe at home. It does not appear that these were factored into his inability to engage with the team. ”
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 Daryel Care; that does not assign responsibility.
PFD Monitor interpretation
Failure to award medical points despite evidence of unsuitable accommodation and health needs
Wider context from the report
“Derrick was provided with a wheeled walker to reduce the risk of falls. Although Derrick’s temporary accommodation was ground floor, there were steps down from the building to street level and he was thus unable to manoeuvre the walker out of the property. Despite a social care letter of support, outlining concerns that his current accommodation was unsuitable and detailing Derrick’s health problems, the housing options team did not award him any medical points. ”
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 Daryel Care; that does not assign responsibility.
PFD Monitor interpretation
Failure to escalate significant post-fall injuries for medical review
Wider context from the report
“On 20 February Derrick suffered a fall. Severe bruising and swelling developed on his face over the following days but this was not recorded in his care notes by his carers and not escalated until his daughter raised concerns on 24 February. “No concerns” was written in Derrick’s care record and no consideration given to whether he needed to be reviewed by a doctor. ”
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 Daryel Care; that does not assign responsibility.
PFD Monitor interpretation
Inaccessible temporary accommodation for wheeled-walker use
Wider context from the report
“Derrick was provided with a wheeled walker to reduce the risk of falls. Although Derrick’s temporary accommodation was ground floor, there were steps down from the building to street level and he was thus unable to manoeuvre the walker out of the property. Despite a social care letter of support, outlining concerns that his current accommodation was unsuitable and detailing Derrick’s health problems, the housing options team did not award him any medical points. ”
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
Update care-documentation guidance and training with structured prompts for detailed injury descriptions and recording the rationale for non-escalation after initial reporting.

Verbatim wording from the response
“5. Actions Taken and Proposed Further Action Daryel Care is committed to learning from this incident and has taken and proposes the following actions to mitigate the risk of future similar occurrences:”

Source location
Response from Daryel Care
Page 3 · response
Published 31 March 2025
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
Deliver mandatory refresher training on falls, head-injury recognition, recording, and escalation protocols to all care staff.

Verbatim wording from the response
“5. Actions Taken and Proposed Further Action Daryel Care is committed to learning from this incident and has taken and proposes the following actions to mitigate the risk of future similar occurrences:”

Source location
Response from Daryel Care
Page 3 · response
Published 31 March 2025
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
Enhance digital photographic injury-upload capability, obtaining explicit client consent in accordance with policy, to supplement written care-note descriptions.

Verbatim wording from the response
“5. Actions Taken and Proposed Further Action Daryel Care is committed to learning from this incident and has taken and proposes the following actions to mitigate the risk of future similar occurrences:”

Source location
Response from Daryel Care
Page 3 · response
Published 31 March 2025
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
Prior hospital assessment, existing MDT escalation, no acute red flags, and imminent care handover supported continued observation without separate immediate medical re-escalation.

Verbatim wording from the response
“e. Consideration of Medical Review The PFD report raises concern that "no consideration given to whether he needed to be reviewed by a doctor." Daryel Care staff were operating within a complex multi-agency framework where clinical oversight, particularly post-discharge and concerning medication, was understood to be led by the Whittington Health Rapid Response team. The decision-making process regarding further medical review by Daryel Care staff considered the following factors: Firstly, Mr Tully had been assessed and treated at the hospital A&E department immediately following his fall on 20 February and was discharged home. Additionally, Daryel Care had formally escalated the head injury to the MDT (including Rapid Response) on the evening of 20 February. Observations during visits on 21 and 22 February recorded pain (on the 21st) and a swollen eye (on the 22nd).”

Source location
Response from Daryel Care
Page 2 · response
Published 31 March 2025
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 fall and developing injury were recorded in care notes, and the head injury was escalated promptly to the multi-disciplinary team.

Verbatim wording from the response
“a. Recording of the Fall Incident (20 February 2024) The assertion that the fall incident was "not recorded" is factually incorrect based on Daryel Care's existing records. The electronic care note entry for the visit commencing at 19:00 hrs on 20 February 2024, logged at 19:04 hours, explicitly documents the following: “The carer observed Mr Tully upon arrival with a fresh plaster wrap and wound dressing on his scalp. Mr Tully informed the carer he had sustained an injury from a fall. The carer”

Source location
Response from Daryel Care
Page 1 · response
Published 31 March 2025
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
No inappropriate “No concerns” entry attributable to staff was found in the official electronic care records, so its origin and context cannot be confirmed.

Verbatim wording from the response
“d. Reference to "No Concerns" Entry The PFD report states, ““No concerns” was written in Derrick’s care record". Daryel Care utilises the CM2000 electronic care monitoring and recording system for all care work visit notes. A review of all CM2000 electronic care notes logged by Daryel Care staff for Mr Tully between 20 February 2024 and the final visit on 22 February 2024 has been conducted. This comprehensive review has not located any entry made by a Daryel Care staff member within the CM2000 system during this period that contains the phrase "No concerns" or substantively similar wording used in an inappropriate context (i.e., as an overall assessment negating the known head injury). All located notes contain specific details pertinent to the care provided and observations made, including the entries regarding the head injury referenced above.”

Source location
Response from Daryel Care
Page 2 · response
Published 31 March 2025
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
Clinical oversight, including decisions about post-discharge medical review, was understood to be led by the Rapid Response team within the multi-agency framework.

Verbatim wording from the response
“e. Consideration of Medical Review The PFD report raises concern that "no consideration given to whether he needed to be reviewed by a doctor." Daryel Care staff were operating within a complex multi-agency framework where clinical oversight, particularly post-discharge and concerning medication, was understood to be led by the Whittington Health Rapid Response team. The decision-making process regarding further medical review by Daryel Care staff considered the following factors: Firstly, Mr Tully had been assessed and treated at the hospital A&E department immediately following his fall on 20 February and was discharged home. Additionally, Daryel Care had formally escalated the head injury to the MDT (including Rapid Response) on the evening of 20 February. Observations during visits on 21 and 22 February recorded pain (on the 21st) and a swollen eye (on the 22nd).”

Source location
Response from Daryel Care
Page 2 · response
Published 31 March 2025
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 raised7

Failure to record significant post-fall injuries in care notes

Failure to assess reablement suitability in light of cognitive impairment and unreliable self-reporting

Failure to provide emergency access to the flat for carers and emergency services

Failure to account for cognitive, mental health and home-safety barriers when assessing engagement

Failure to award medical points despite evidence of unsuitable accommodation and health needs

Failure to escalate significant post-fall injuries for medical review

Inaccessible temporary accommodation for wheeled-walker use

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.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.4

Actions described in response 3

Respondent positions 4