Recipient

LNT Software

First report 30 Aug 2013•Latest report 30 Aug 2013

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

30 Aug2013
South Yorkshire (Western)
Concerns raised11
1. Insufficient staff training
2. Failure to develop risk reduction plans when mandated by risk assessments
3. Failure to complete and reconcile pre-admission and admission assessments
1. Failure to develop and review care plans that adequately recognise residents’ needs
2. Insufficient staff supervision
3. Failure to obtain community care assessments
4. Possible failure to act on accident reports through risk or repeat-incident prevention strategies
5. Confusion among staff about whether to call an ambulance or the out-of-hours GP service
6. Failure to implement available preventative measures based on known or reasonably available information
7. Failure to conduct adequate risk assessments using all known and reasonably available information
8. Lack of cohesive management
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mrs May Gibson · 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

Mrs May Gibson sustained fatal injuries in a significant fall in her room at Herries Lodge Care Home on 21 March 2013. The report identified failures in assessment, care planning, falls risk management, preventative measures, and staff training and supervision; the inquest found that her death was contributed to by neglect.

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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staff training
Wider context from the report
“9) the evidence as a whole gave a picture of an establishment that had no cohesive management at the time, with staff who were caring but insufficiently trained and supervised. ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Failure to develop risk reduction plans when mandated by risk assessments
Wider context from the report
“5) the failure to develop a risk reduction plan when mandated by the risk assessment, even as it was actually completed; ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete and reconcile pre-admission and admission assessments
Wider context from the report
“2) the failure to make a proper pre-assessment, or query the differences in assessment with the City Council, or to make a further assessment upon admission; ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Failure to develop and review care plans that adequately recognise residents’ needs
Wider context from the report
“3) the failure to develop a care plan which recognised Mrs Gibson’s needs adequately, whether initially or by review after she had fallen on several occasions within the Home; ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staff supervision
Wider context from the report
“9) the evidence as a whole gave a picture of an establishment that had no cohesive management at the time, with staff who were caring but insufficiently trained and supervised. ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Failure to obtain community care assessments
Wider context from the report
“1) the failure to obtain the community care assessment and to take proper account of this in developing a care plan; ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Possible failure to act on accident reports through risk or repeat-incident prevention strategies
Wider context from the report
“8) whilst not explored at the inquest, it may be that no managerial action was taken on the accident report forms to ensure that they were properly followed up with risk or repeat incident prevention strategies 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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Confusion among staff about whether to call an ambulance or the out-of-hours GP service
Wider context from the report
“7) although not causative of Mrs Gibson’s death, there was confusion amongst staff as to the circumstances in which an ambulance should be called as opposed to contacting the out of hours GP service; ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Failure to implement available preventative measures based on known or reasonably available information
Wider context from the report
“6) the failure to take available preventative measures given the information that was known or should have been known; ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct adequate risk assessments using all known and reasonably available information
Wider context from the report
“4) the failure to risk assess adequately, taking account of all information that was known, let alone information that should have been known; ”
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 LNT Software; that does not assign responsibility.
PFD Monitor interpretation
Lack of cohesive management
Wider context from the report
“9) the evidence as a whole gave a picture of an establishment that had no cohesive management at the time, with staff who were caring but insufficiently trained and supervised. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised11

Insufficient staff training

Failure to develop risk reduction plans when mandated by risk assessments

Failure to complete and reconcile pre-admission and admission assessments

Failure to develop and review care plans that adequately recognise residents’ needs

Insufficient staff supervision

Failure to obtain community care assessments

Possible failure to act on accident reports through risk or repeat-incident prevention strategies

Confusion among staff about whether to call an ambulance or the out-of-hours GP service

Failure to implement available preventative measures based on known or reasonably available information

Failure to conduct adequate risk assessments using all known and reasonably available information

Lack of cohesive management