Concerns raised 3 Failure to accurately record medical information including vital signs View source Lack of care and nursing staff awareness of the risks of medical complications following falls and long lies View source Failure of care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical emergency View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 2
Action
Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
View source
Action
Use Care Control for documentation and care planning, with staff trained to complete appropriate and adequate records.
View source
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AI-generated summary
Clara Ellen Freeman · 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
Clara Ellen Freeman suffered an unwitnessed fall at a care home and remained immobilised on the floor for approximately four hours while awaiting an ambulance. She later died in hospital after developing medical complications. The principal concerns related to staff proficiency in caring for her after the fall and communicating relevant information, including changes in her condition, to the ambulance service.
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 Hart Care Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record medical information including vital signs
Wider context from the report “(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition.
It is requested that the training for care and nursing staff be reviewed to consider;
a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency
b) Accurate recording of medical information including vital signs
c) Awareness of the risks of medical complications following falls and long lies.
” 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 Hart Care Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of care and nursing staff awareness of the risks of medical complications following falls and long lies
Wider context from the report “(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition.
It is requested that the training for care and nursing staff be reviewed to consider;
a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency
b) Accurate recording of medical information including vital signs
c) Awareness of the risks of medical complications following falls and long lies .
” 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 Hart Care Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical emergency
Wider context from the report “(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition .
It is requested that the training for care and nursing staff be reviewed to consider;
a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency
b) Accurate recording of medical information including vital signs
c) Awareness of the risks of medical complications following falls and long lies.
” 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 Provide first aid training to all staff responsible for shifts, covering emergency response, falls, choking, bleeding, CPR and related care.
Verbatim wording from the response “In accordance with the Regulation 28 Report to Prevent Future Deaths dated 26th March 2021, I write to confirm that we have taken action and all our staff members who are in charge of shifts in the home have attended First Aid Training on the 11th and 13th May 2021 in addition to the mandatory training programme we have in place.” Source location 2021-0085-Response-from-Hart-Care-Redacted
Open published response
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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 Use Care Control for documentation and care planning, with staff trained to complete appropriate and adequate records.
Verbatim wording from the response “We are currently using a system called “Care Control” for our documentation and care planning and the staff are all trained with what is appropriate and necessary to document. They all understand the importance of appropriate and adequate documentation.” Source location 2021-0085-Response-from-Hart-Care-Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations