Recipient

Hillbrook Grange

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First report 24 Aug 2017•Latest report 24 Aug 2017

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
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
1

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.

100%published responses found
1stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Hillbrook Grange linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Joseph Tarnowski · 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

    Joseph Tarnowski, who was aged 96, fell while getting changed in his bedroom at Hillbrook Grange on 7 April 2017 and sustained a displaced fracture of the neck of his left humerus. He died at Stepping Hill Hospital on 10 April 2017; the inquest recorded the conclusion as Accident, with the medical cause of death including bronchopneumonia, acute heart failure, immobility, and the fall with fractured humerus. Concerns included whether Mr Tarnowski knew that his wireless call-bell could be moved and whether he could move it while relying on a mobility aid, as well as consideration of wearable call bells.

    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 Hillbrook Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Residents' lack of awareness that wireless call-bells can be moved around their rooms

    Wider context from the report

    “In evidence at the inquest, it was confirmed that Mr Tarnowski summoned assistance by shouting out to staff rather than by using his call-bell. It became apparent during the course of the hearing that Mr Tarnowski may not have been aware that his call-bell was wireless, and as such could be moved around his room. Additionally, the evidence revealed that even had Mr Tarnowski been aware that his call-bell was portable, he may not have been able to move it due to his reliance on a mobility aid. At the time of the inquest, consideration had not been given to introducing call bells which are worn by residents of fashion that are apparently in use in some other similar residential care setting. ”
    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 Hillbrook Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Inability of residents reliant on mobility aids to move portable call-bells

    Wider context from the report

    “In evidence at the inquest, it was confirmed that Mr Tarnowski summoned assistance by shouting out to staff rather than by using his call-bell. It became apparent during the course of the hearing that Mr Tarnowski may not have been aware that his call-bell was wireless, and as such could be moved around his room. Additionally, the evidence revealed that even had Mr Tarnowski been aware that his call-bell was portable, he may not have been able to move it due to his reliance on a mobility aid. At the time of the inquest, consideration had not been given to introducing call bells which are worn by residents of fashion that are apparently in use in some other similar residential care setting. ”
    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 Hillbrook Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consider wearable call-bells for residents

    Wider context from the report

    “In evidence at the inquest, it was confirmed that Mr Tarnowski summoned assistance by shouting out to staff rather than by using his call-bell. It became apparent during the course of the hearing that Mr Tarnowski may not have been aware that his call-bell was wireless, and as such could be moved around his room. Additionally, the evidence revealed that even had Mr Tarnowski been aware that his call-bell was portable, he may not have been able to move it due to his reliance on a mobility aid. At the time of the inquest, consideration had not been given to introducing call bells which are worn by residents of fashion that are apparently in use in some other similar residential care setting. ”
    Open source report

    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 residents with wearable mobile call bells to summon assistance after falls.

    Verbatim wording from the response

    “I am happy to say that from this verdict and report we have taken prompt and responsive action by way of providing residents with call bells that are to be worn around their necks. This was immediately actioned following the registered manager’s participation into the inquest. Consequently, the board of directors approved and purchased the call bells without delay and the system was implemented within the week.”

    Source location

    2017-0247-Response-by-Hillbrook-Grange_Redacted
    Page 1 · response
    Published 1 October 2017

    Open published response
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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

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
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