Recipient

Friend of the deceased

First report 27 Oct 2023•Latest report 27 Oct 2023

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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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

27 Oct2023
Avon
Concerns raised7
1. Insufficient specialist medical capacity for timely and proactive care of older hospital patients
2. Inadequate ambulance staff training in recognising and dealing with patients who have fallen
3. Failure of ambulance staff to recognise falls risk and initiate further action
1. Failure to identify and apply learning from falls-related incidents
2. Failure to complete falls risk assessments in accordance with JRCALC guidelines
3. Lack of clear guidelines for holistic management of older hospital patients
4. Hospital falls causing fatal injuries
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

Gerald Roy Cruse · 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

Gerald Cruse fell from a bed while being assisted to use the toilet in an ambulance cohort area after admission following a fall at home. He sustained multiple rib fractures, a haemopneumothorax and surgical emphysema, later developed pneumonia, and died in hospital. Concerns included inadequate falls-risk assessment and recognition by ambulance staff, a lack of identified learning after investigation, and wider concerns about the organisation of care for older patients requiring both surgical and geriatric medical input.

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 Friend of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Insufficient specialist medical capacity for timely and proactive care of older hospital patients
Wider context from the report
“(1) That over 75% of patients receiving hospital care are 65 and over. There is a conflict and tension between where within the hospital those patients should be receiving their care. A proportion of these patients require admission to a surgical ward due to the elements of their care which require surgical oversight and management, for example, analgesia through an epidural, insertion of a chest drain. However, this group of patients have multiple co-morbidities and complexities due to their age, which would be better managed by a medical team specialising in care of the elderly. Whilst medical teams can review patients, their limited resources mean it may not be as quickly as it needs to be, and they cannot be proactive in following up on the care of these patients. This results in an increasing risk that these patients will not receive the care they need in a timely manner. There is an increasing need for more doctors specialising in the care of older persons and this is a national issue. ”
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 Friend of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Inadequate ambulance staff training in recognising and dealing with patients who have fallen
Wider context from the report
“(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future. Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or 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 Friend of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Failure of ambulance staff to recognise falls risk and initiate further action
Wider context from the report
“(5) The other two ambulance staff did not seem to understand that Mr Cruse was a falls risk, they did not consider that he was at a greater risk of falls and did not consider that any further action should have been considered or taken. ”
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 Friend of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify and apply learning from falls-related incidents
Wider context from the report
“(6) An investigation took place but the staff did not identify any learning and did not undertake the case study to help them identify such patients in the future. Bristol Ambulance Emergency Medical Services still run some cohort areas alongside South Western Ambulance NHS Foundation Trust, and continue to convey patients to hospital. The evidence given on behalf of this organisation did not provide reassurance that this is a matter which the ambulance service have adequately addressed. There is a real concern that ambulance staff throughout the organisation may not be adequately trained in recognising and dealing with patients who have had a fall or 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 Friend of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete falls risk assessments in accordance with JRCALC guidelines
Wider context from the report
“(4) The paramedic working within the cohort area did not complete a falls risk assessment in accordance with the JRCALC guidelines following the admission of a patient who had just had a fall at home. ”
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 Friend of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear guidelines for holistic management of older hospital patients
Wider context from the report
“(2) There are currently no clear guidelines as to how these patients should best be managed and there remains a serious risk that the care they receive is not holistic. ”
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 Friend of the deceased; that does not assign responsibility.
PFD Monitor interpretation
Hospital falls causing fatal injuries
Wider context from the report
“(3) Patients falling in hospitals and sustaining injuries which lead to their death remains a matter of grave concern. ”
Open source report

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

Insufficient specialist medical capacity for timely and proactive care of older hospital patients

Inadequate ambulance staff training in recognising and dealing with patients who have fallen

Failure of ambulance staff to recognise falls risk and initiate further action

Failure to identify and apply learning from falls-related incidents

Failure to complete falls risk assessments in accordance with JRCALC guidelines

Lack of clear guidelines for holistic management of older hospital patients

Hospital falls causing fatal injuries