Recipient

Daughter of the deceased

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First report 21 Apr 2015•Latest report 21 Apr 2015

Recipient record

Reports, concerns and published responses

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 Daughter of the deceased linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Howell Glyndwr Fisher · 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

    Howell Glyndwr Fisher fell at home, sustained a fractured hip, and later died in hospital on 9 December 2014 after developing an ischemic leg, pneumonia and other health problems. The concerns included at least five falls while he was assessed as being at high risk, insufficient staffing to provide required one-to-one nursing, and inadequate handover and falls-risk assessments between and within hospitals.

    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 Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of transfer handover information about high falls risk

    Wider context from the report

    “(2) There was no “handover material” at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out – indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken. Throughout he remained at high risk of falls. ”
    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 Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out falls risk assessments on readmission and after successive falls

    Wider context from the report

    “(2) There was no “handover material” at the point of transfer between the two hospitals detailing that he was at high risk of falls and further more on readmission to the Princess of Wales Hospital on the 20th November no falls risk assessment was carried out – indeed, after each successive fall in the Princess of Wales Hospital no formal assessment appears to have been undertaken. Throughout he remained at high risk of falls. ”
    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 Daughter of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing for required one-to-one nursing observation of patients at high risk of falls

    Wider context from the report

    “(1) Within the space of a month the deceased had at least 5 falls whilst being deemed as high risk of falls. He was identified as requiring one to one nursing but there were many occasions when insufficient staff numbers meant that this could not be delivered. ”
    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