Langley Trust

Housing · Registered provider of social housing

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First report 1 Feb 2023•Latest report 1 Feb 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

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

  1. Gwent

    AI-generated summary

    Mary Doreen White · 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

    Mary Doreen White was admitted to hospital in April 2021 and suffered three falls while an inpatient, including fractures requiring surgery. Her condition deteriorated while recovering from surgery, and she died from a chest infection, with frailty of old age also recorded. Concerns included staffing shortages, difficulties providing required enhanced observation on the ward, and the absence of a documented and communicated plan for managing patients requiring Level 4 enhanced care in that setting.

    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 Langley Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a documented contingency plan for managing patients when staffing shortages prevent their assessed level of care

    Wider context from the report

    “1. Despite requesting additional nursing staff, the Bargoed ward was short-staffed when Mrs White fell. There did not appear to be any documented plan or procedure in place for how patients would be safely managed when it was not possible (because of staff shortage) to carry out the level of care for individual patients that they had been assessed as requiring. ”
    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 Langley Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of clip-on alarm sensors to remain attached and effective

    Wider context from the report

    “4. To further counteract the difficulties with observing patients on Enhanced Level 4 care it was explained that clip-on alarm sensors were used. There was evidence given that patients are able to simply unclip these sensors, rendering the system ineffective. ”
    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 Langley Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide continuous in-view observation for Level 4 enhanced care patients

    Wider context from the report

    “2. The ward is L-shaped and the patients on the ward are managed in individual cubicles. Mrs White should have been in view of nursing staff as part of her Level 4 enhanced care (‘observation of cohorted patients’). However, it was not possible to provide the observations that Mrs White required because: a. Patients were inside cubicles and therefore out of sight of staff and, b. The ward itself was L-shaped. 3. The Bargoed ward is a stroke ward and one where it is usual to see patients who have a high risk of falls and mobility difficulties. Prior to Covid-19 it was explained that staff would take patients who required the Enhanced Care to the dayroom so that they could be under the required observation. Since Covid-19, this had not been possible. To counteract the logistical difficulties faced by staff in observation of Enhanced Care patients on the ward it was explained that patients are now moved to their cubicle doorway for periods of the day so that they are in sight of nursing staff. This appeared to be ineffective because: a. The particular care needs/wishes of a patient may mean that is not suitable. b. That only accounts for part of the day. ”
    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 Langley Trust; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a made and communicated plan for managing Level 4 patients in a single-room environment

    Wider context from the report

    “A Falls Review Panel had noted that Providing Level 4 Enhanced Care on this ward was extremely challenging and that quality care at Level 4 was unachievable in a single room environment. It was noted that the Corporate Nursing Team had reviewed the Enhanced Care Policy in light of the fact it did not fit single room environment, however at the time of the inquest it did not appear from evidence received that a plan to manage Level 4 patients on this ward had been made and/or communicated to staff. ”
    Open source report
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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