6 Sep 2013 Peter Pattinson · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 6 Failure to act on family concerns and requests about bed rails View source Failure to risk assess family concerns and bed-rail requests View source Missing daily statements from patient files View source Failure to document family concerns and bed-rail requests View source Delays in repairing bed rails View source Failure to paginate daily statements sequentially View source See 3 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
Peter Pattinson · 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
Peter Pattinson, who had complex medical needs, was readmitted to hospital after falling from his bed at Cedar Court Care Centre and died on 19 March 2013. Concerns included family requests for raised bed rails not being acted on or documented or subject to risk assessment, delayed repair of the bed rails, and missing or non-sequentially paginated daily statements.
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 European Care & Lifestyles (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to act on family concerns and requests about bed rails
Wider context from the report “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment.
2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way.
3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs)
4. The daily statements that were provided were not paginated sequentially.
” 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 European Care & Lifestyles (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to risk assess family concerns and bed-rail requests
Wider context from the report “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment .
2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way.
3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs)
4. The daily statements that were provided were not paginated sequentially.
” 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 European Care & Lifestyles (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Missing daily statements from patient files
Wider context from the report “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment.
2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way.
3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs)
4. The daily statements that were provided were not paginated sequentially.
” 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 European Care & Lifestyles (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document family concerns and bed-rail requests
Wider context from the report “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented , and were not subject to a risk assessment.
2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way.
3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs)
4. The daily statements that were provided were not paginated sequentially.
” 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 European Care & Lifestyles (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in repairing bed rails
Wider context from the report “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment.
2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way.
3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs)
4. The daily statements that were provided were not paginated sequentially.
” 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 European Care & Lifestyles (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to paginate daily statements sequentially
Wider context from the report “1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment.
2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way.
3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs)
4. The daily statements that were provided were not paginated sequentially.
” Open source report
Concerns raised 2 Failure of the complaints procedure to escalate concerns to senior management View source Lack of information directing persons with concerns to senior management View source
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
Clive William · 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
Clive William, a resident at Cae Glas Psychiatric Rehabilitation Care Home, died in bed on 21 October 2013. Concerns were raised about poor standards of care, missed medication and appointments, and a complaints process that could prevent concerns reaching senior management, potentially leaving residents at risk of harm.
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 European Care & Lifestyles (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of the complaints procedure to escalate concerns to senior management
Wider context from the report “(1) Evidence was given by the family of Mr Clinton that they had complained to the manager of the Care Home on several occasions about the standard of care which was being provided to Mr Clinton, namely that they would often find him drenched in urine and faeces, that his soiled bedding and clothing would be left in his room, that there were occasions when he would not receive his prescribed medication and that he would sometimes medical appointments which had been arranged for him.
(2) Evidence was also given by a representative of European Care who own the care home, confirming that although a complaints procedure exists within the organisation, the concerns of the family in this instance had not reached a senior level as should happen so that action could be taken .
(3) My concerns relate to the apparent failings of a complaints procedure in which staff can effectively withhold concerns from senior management and the lack of information within the care home that could advise persons with concerns as to how they may direct their complaints to a more senior level of management within the organisation. In the absence of a truly robust system of complaint, it is possible that concerns may not be addressed in a timely fashion or at all and could ultimately place residents at risk of harm.
” 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 European Care & Lifestyles (UK) Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of information directing persons with concerns to senior management
Wider context from the report “(1) Evidence was given by the family of Mr Clinton that they had complained to the manager of the Care Home on several occasions about the standard of care which was being provided to Mr Clinton, namely that they would often find him drenched in urine and faeces, that his soiled bedding and clothing would be left in his room, that there were occasions when he would not receive his prescribed medication and that he would sometimes medical appointments which had been arranged for him.
(2) Evidence was also given by a representative of European Care who own the care home, confirming that although a complaints procedure exists within the organisation, the concerns of the family in this instance had not reached a senior level as should happen so that action could be taken.
(3) My concerns relate to the apparent failings of a complaints procedure in which staff can effectively withhold concerns from senior management and the lack of information within the care home that could advise persons with concerns as to how they may direct their complaints to a more senior level of management within the organisation . In the absence of a truly robust system of complaint, it is possible that concerns may not be addressed in a timely fashion or at all and could ultimately place residents at risk of harm.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations