Recipient

Dovecote Lodge

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First report 25 Jul 2014•Latest report 25 Jul 2014

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 Dovecote Lodge linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire (Western)

    AI-generated summary

    Edna Bulmer · 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

    Edna Bulmer, who had a history of falls, suffered an unwitnessed fall on 10 September 2013 and was later found unconscious in bed. She died in hospital on 15 September 2013 after sustaining a serious intracranial haemorrhage. The concerns identified were inconsistent recording of her falls risk, delays in providing the identified pressure mat and pendant, and the apparent absence of a clear process for reviewing her risk assessment after further falls.

    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 Dovecote Lodge; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of clear and consistent identification of falling risk levels in records

    Wider context from the report

    “(1) There did not appear to be a clear identification of the level of risk of Mrs. Bulmer falling made within Dovecote Lodge records. In one section Mrs. Bulmer is described as very high risk, elsewhere she is described as high risk. ”
    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 Dovecote Lodge; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in implementing measures identified to minimise falling risk

    Wider context from the report

    “(2) The measures identified within the Personal Risk Assessment to minimise risk were not implemented (provision of mat and pendant) until several days after Mrs. Bulmer’s arrival, after a number of incidents had occurred. ”
    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 Dovecote Lodge; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review the risk assessment after further falls

    Wider context from the report

    “(3) There did not appear to have been a review of the risk assessment after further fall incidents. Is there a system in place which requires a further review of the Personal Risk Assessment? If so, who has responsibility to undertake such a review? If such system does exist has it been effectively communicated to all staff members, including management? ”
    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