Recipient

Lambton House

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First report 29 Nov 2016•Latest report 29 Nov 2016

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
200%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
9

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.

200%published responses found
9stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. County Durham and Darlington

    AI-generated summary

    Name not published · 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

    The deceased, who had a history of falls and was assessed as being at risk of falling, was found on the floor after an unwitnessed night and sustained injuries that subsequently led to her death. Concerns included the absence of adequate risk assessments for falls and pressure sores, and the failure to identify that a new mattress was unsuitable for her.

    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 Lambton House; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify unsuitable mattresses for care recipients

    Wider context from the report

    “(2) It became apparent that the new mattress was not suitable for the deceased and that this had not been adequately identified. ”
    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 Lambton House; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of risk assessment for falls and pressure sore risk

    Wider context from the report

    “(1) It became apparent that a risk assessment was not completed in relation to the deceased's falls and the pressure sore risk. The deceased was found on the floor after an unwitnessed night by a carer at approximately 4.00 hours. She sustained injuries which subsequently led to her death. ”
    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

    Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.

    Verbatim wording from the response

    “Steps are being taken to further minimise the risk that resident's face in situations such as this. Lambton House is currently in the process of phasing in through “Home Loans” the provision of air flow mattresses, where there has been an assessed need to aid pressure relief care. All new air flow mattresses are compatible with bed based pressure sensors. The aim is to eliminate the need for floor based pressure sensors, which in themselves can also create a risk of falls/trips.”

    Source location

    2016-0423-Response-by-Lambton-House-Care-Home
    Page 1 · response
    Published 26 February 2017

    Open published response

    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

    Install pressure mats whenever a mattress is incompatible with bed sensors.

    Verbatim wording from the response

    “Staff at Lambton House did recognise that a pressure sensor needed to be placed next to the deceased's bed and attempts were made to try to have a floor pressure sensor mat installed next to the deceased's bed. Unfortunately at that time this required a specialist contractor to attend to install the mat and incorporate it into the building's existing alarm system. That change could not take place that day. Unfortunately the deceased suffered a fall later that evening. It is now standard practice for pressure mats to be installed in all cases where a mattress is used that is incompatible with bed sensors.”

    Source location

    2016-0423-Response-by-Lambton-House-Care-Home
    Page 1 · response
    Published 26 February 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

200%
200%All other recipients 58%
0%100%

How actions were described at the time

This respondent
78%11%11%
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