19 Jun 2025 Vera Fortey · Prevention of Future Deaths report Worcestershire
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Concerns raised 6 Failure to recognise post-fall deterioration and seek timely medical assessment View source Failure to record significant incidents contemporaneously in residents’ records View source Insufficient measures to ensure staff understand significant-incident recording requirements View source Lack of regular auditing of residents’ records View source Insufficient familiarity with the computerized care-records system View source Failure to identify missing incident documentation during care-record review View source See 3 more concerns
Responses linked to these concerns
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AI-generated summary
Vera Fortey · 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
Vera Fortey suffered an unwitnessed fall at her care home, after which her mobility and condition deteriorated. Her fractured hip was not medically identified for approximately two and a half days, and she later underwent surgery, declined despite treatment, and died in hospital. The principal concerns were inadequate recording of the fall, missed opportunities to obtain medical assessment, insufficient auditing of residents’ records, and inadequate staff familiarity with the care home’s records system.
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 Green Range Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise post-fall deterioration and seek timely medical assessment
Wider context from the report “3) Before the fall in the early hours of 25.9.24 Mrs. Fortey was able to mobilise independently. After the fall, a number of entries were made in Mrs. Fortey’s Daily Notes, which referred to her:
- Being unable to support herself, having bad mobility and requiring a wheelchair ( 1626hrs 25.9.24 );
- Having very bad mobility and requiring a wheelchair ( 1848hrs 26.9.24 );
- Being very confused and agitated, with very bad mobility ( 0713hrs 27.9.24 );
Despite these obvious changes in her condition, no member of staff identified that these changes might have been due to the fall on 25.9.24 . Therefore in the 2½ days after the fall, several opportunities were missed to have Mrs. Fortey medically examined , and for her fractured hip to have been identified and treated sooner. A significant reason for these opportunities being missed was the fact that the original fall was not documented in Mrs. Fortey’s file.
” 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 Green Range Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record significant incidents contemporaneously in residents’ records
Wider context from the report “1) Mrs. Fortey suffered an unwitnessed fall in her room at The Willows Care Home, Worcester shortly after midnight on 25.9.24. The carers who came and assisted her felt that she had not injured herself, and did not seek any medical attention for her. In fact, no medical attention was sought until shortly before midday on 27.9.24, when she was recorded as not being able to support her own body weight. The disclosure provided by the care home for the inquest did not contain:
- any contemporaneous account of this fall written by either of the two carers who dealt with her at the time ;
- any entry made in Mrs. Fortey’s Daily Notes of this fall .
Furthermore, although there was a document which the then manager of the care home had written, which was said to summarize the accounts of the fall given to her by the carers concerned, this document made no reference to the date of the fall;
I was forced to conclude that no contemporaneous account of the fall on 25.9.24 ever made its way to Mrs. Fortey’s file .
” 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 Green Range Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient measures to ensure staff understand significant-incident recording requirements
Wider context from the report “4) Although she had only been in post since 13 August 2024, the then care home manager told the inquest that a reason why she may not herself have picked up on the above failings was because at the time of these events, she was still not familiar with the care home’s records system, was unable to scroll through residents’ notes, and was instead just “muddling through”.
It therefore appears that insufficiently robust measures are in place at The Willows Care Home to ensure :
(a) that staff understand the need to record significant incidents in residents’ records ;
(b) that a regular auditing procedure is in place to help ensure that residents’ records are being updated properly; and
(c) that all staff at the care home ( including managers ) have received training so as to be as familiar with the computerized records system in use there as their role may require.
” 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 Green Range Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of regular auditing of residents’ records
Wider context from the report “4) Although she had only been in post since 13 August 2024, the then care home manager told the inquest that a reason why she may not herself have picked up on the above failings was because at the time of these events, she was still not familiar with the care home’s records system, was unable to scroll through residents’ notes, and was instead just “muddling through”.
It therefore appears that insufficiently robust measures are in place at The Willows Care Home to ensure:
(a) that staff understand the need to record significant incidents in residents’ records;
(b) that a regular auditing procedure is in place to help ensure that residents’ records are being updated properly ; and
(c) that all staff at the care home ( including managers ) have received training so as to be as familiar with the computerized records system in use there as their role may require.
” 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 Green Range Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient familiarity with the computerized care-records system
Wider context from the report “4) Although she had only been in post since 13 August 2024, the then care home manager told the inquest that a reason why she may not herself have picked up on the above failings was because at the time of these events, she was still not familiar with the care home’s records system , was unable to scroll through residents’ notes , and was instead just “muddling through”.
It therefore appears that insufficiently robust measures are in place at The Willows Care Home to ensure:
(a) that staff understand the need to record significant incidents in residents’ records;
(b) that a regular auditing procedure is in place to help ensure that residents’ records are being updated properly; and
(c) that all staff at the care home ( including managers ) have received training so as to be as familiar with the computerized records system in use there as their role may require .
” 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 Green Range Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to identify missing incident documentation during care-record review
Wider context from the report “2) The then care home manager was informed by telephone about the fall at the time, and later on the morning of 25.9.24 reviewed Mrs. Fortey’s care plans. At no time did she pick up on the fact that no account of the fall was contained on Mrs. Fortey’s file .
” Open source report
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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 Provided fall prevention and management training to staff.
Verbatim wording from the response “As part of the action plan, fall prevention and management training was provided by Acute Training Solutions Limited on 24 July 2025. A copy of the training certificates is contained at Appendix 2. Page 17 of the appendices outlines the learning objectives for the course.” Source location Response from The Willows Care Home
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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 Developed an action plan addressing unwitnessed falls, medical attention, record keeping, auditing and staff training.
Verbatim wording from the response “To address the specific items raised in the Regulation 28 Report we drew up an action plan that covered:” Source location Response from The Willows Care Home
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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 Provided carers and the Home Manager with training on the Care Docs Portal’s core functionality.
Verbatim wording from the response “In addition, further training was provided to the carers and Home Manager on the core functionality of the Care Docs Portal. An outline of the training provided by Care Docs is contained at Appendix 3. I trust that this provides you and Mrs Fortey's family reassurance that the home has taken onboard the concerns raised and made requisite changes.” Source location Response from The Willows Care Home
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations