Concerns raised 9 Failure to formally request one-to-one supervision funding when necessary View source Failure to provide appropriate falls prevention for a resident with evolving dementia View source Failure to escalate a significant number of falls sustained by a frail older person View source Failure to provide organisational learning on accurate reporting and escalation View source Failure to provide training and development on falls prevention View source Failure to conduct appropriate risk assessment for a resident with evolving dementia View source Failure to meet the mobility needs of a resident with evolving dementia View source Failure to provide appropriate supervision for a resident with evolving dementia View source Failure to accurately and promptly report falls and complete falls-prevention referral forms View source See 6 more concerns
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
Julia MURPHY · 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
Julia Murphy, known as Sheila, died in hospital on 9 April 2023 after a fall in her care home caused a hip fracture and her condition deteriorated. The report raises concerns about repeated falls, incomplete or inaccurate referrals to the falls prevention team, inadequate escalation, and failure to formally seek one-to-one supervision funding where appropriate.
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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to formally request one-to-one supervision funding when necessary
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate falls prevention for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate a significant number of falls sustained by a frail older person
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide organisational learning on accurate reporting and escalation
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide training and development on falls prevention
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct appropriate risk assessment for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to meet the mobility needs of a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility , supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate supervision for a resident with evolving dementia
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately and promptly report falls and complete falls-prevention referral forms
Wider context from the report “Julia had 21 falls, the final fall led to her death. The 3 referral forms sent to falls prevention were incomplete, misleading and/or inaccurate. An action plan in respect of preventing future deaths from falls/falls prevention/the learning following these events was not presented at Inquest nor did there appear to be a clear plan to address inter alia;
1. Accurate/timely reporting of falls/accurate timely, completion of referral forms to the falls prevention team .
2. Escalation when such a significant number of falls were sustained by 1 frail, elderly person. 3. Meeting the needs of the resident with evolving dementia, particularly in respect of mobility, supervision, falls prevention and risk assessment.
4. Formally requesting 1-1 supervision funding when necessary/as appropriate on a case by case basis.
5. Training/development/organisational learning following these events re falls prevention and accurate reporting/escalation.
The above list is not exhaustive and the care home management/owners will be best placed to develop their own action plan following the death of Julia.
” Open source report
Concerns raised 10 Failure to provide appropriately pureed food and eating assistance View source Failure to provide requested toileting assistance View source Delays in treating oral thrush View source Failure of allocated ward staff to remain awake and attentive View source Delays in referral to the speech and language team View source Inaccurate recording of patients’ continence status View source Failure to recognise opioid sensitivity when prescribing or administering opioids View source Failure to record opioid sensitivity as an alert across care records View source Failure to identify and act on swallowing problems without family prompting View source Failure to keep drinking fluids within reach View source See 7 more concerns
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
Flora Marion BABER · 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
Flora Marion Baber was admitted to the Royal Free Hospital from Compton Lodge Care Home on 25 January 2018 with increased confusion, slurred speech and difficulty breathing, and died there about a month later. Concerns included inadequate access to fluids, inappropriate food and eating assistance, delays in speech and language referral and treatment of oral thrush, an apparently sleeping staff member, inappropriate responses to toileting requests, and failure to record her opioid sensitivity across healthcare settings.
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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriately pureed food and eating assistance
Wider context from the report “1. Whilst record keeping showed Dr Baber as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed.
Also, she did not always receive appropriately pureed food or the assistance that she needed to eat .
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide requested toileting assistance
Wider context from the report “4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent.
Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy , she was wearing an incontinence pad, and she should use that instead .
I was shocked to hear this.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Delays in treating oral thrush
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush .
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of allocated ward staff to remain awake and attentive
Wider context from the report “3. Family members told me that at one point, they found the member of staff allocated to Dr Baber’s bay sitting in a chair apparently asleep .
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to the speech and language team
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush.
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of patients’ continence status
Wider context from the report “4. Dr Baber was noted in the medical records as being doubly incontinent. However, family members told me that she was not incontinent.
Rather, when she asked for assistance to go to the toilet or to use a bedpan (she had poor mobility), a healthcare assistant told her that staff were busy, she was wearing an incontinence pad, and she should use that instead.
I was shocked to hear this.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise opioid sensitivity when prescribing or administering opioids
Wider context from the report “5. Dr Baber had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication.
This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home.
However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes.
At the very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh the side effects of opiates, but before then her sensitivity was simply not recognised .
This caused her discomfort and distress, and in another case could have fatal consequences.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to record opioid sensitivity as an alert across care records
Wider context from the report “5. Dr Baber had a sensitivity to opioids, such that her family noted a direct correlation between episodes of sickness and vomiting, and the administration of opioid medication.
This had been recognised and recorded during earlier admissions to the Royal Free, and family had discussed with staff at the care home.
However, it was not recorded as an alert on her hospital notes, or on her general practitioner notes, or on the care home notes .
At the very end of Dr Baber’s life, the benefit of pain relief was thought to outweigh the side effects of opiates, but before then her sensitivity was simply not recognised.
This caused her discomfort and distress, and in another case could have fatal consequences.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to identify and act on swallowing problems without family prompting
Wider context from the report “2. There was a delay in referring Dr Baber to the speech and language team and in treating her oral thrush.
Most significantly, I heard evidence that it was only when family members pointed out a problem such as pain on swallowing, that staff acted to deal with this .
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to keep drinking fluids within reach
Wider context from the report “1. Whilst record keeping showed Dr Baber as having been given appropriate food and drink whilst on the ward in hospital, I heard that sometimes her nearest fluid was out of her reach on a bedside table too far from the bed .
Also, she did not always receive appropriately pureed food or the assistance that she needed to eat.
” Open source report
18 Apr 2016 Doreen Mattinson · Prevention of Future Deaths report Inner North London
View report summary
Concerns raised 4 Failure to administer the required oxygen flow View source Lack of recognition of the oxygen level required in an emergency situation View source Failure to recognise the importance of sitting the patient in an upright position View source Lack of training of the Clinical Manager to administer oxygen View source See 1 more concern
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
Doreen Mattinson · 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
Doreen Mattinson, an 80-year-old resident of Acorn Care Home with dementia and other comorbidities, deteriorated rapidly with laboured breathing on 12 November 2015. Concerns were raised about the administration of oxygen, including the flow rate, her supine position, and the absence of evidence of training for the registered nurse who administered it.
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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to administer the required oxygen flow
Wider context from the report “(1) The London Ambulance Service attended Mrs Mattinson on 12 November 2015 and made a Safeguarding Report relating to the use of the oxygen. It had been reported that Mrs Mattinson had been lying supine on the bed saturating at 84% and struggling to breath. The oxygen could not be heard to be running and it was noted that only 1 litre was running when this should have been a15 litre flow with the mask applied .
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Lack of recognition of the oxygen level required in an emergency situation
Wider context from the report “(2)There was no recognition by the Clinical Manager or those present on 12 November 2015 of the level of oxygen to be used in an emergency situation or as to the importance of sitting the patient in an upright position.
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the importance of sitting the patient in an upright position
Wider context from the report “(2)There was no recognition by the Clinical Manager or those present on 12 November 2015 of the level of oxygen to be used in an emergency situation or as to the importance of sitting the patient in an upright position .
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Lack of training of the Clinical Manager to administer oxygen
Wider context from the report “(3)There was no evidence of training of the Clinical Manager , who was a registered nurse and the only member of staff on the residential unit on that day who would be expected to administer oxygen .
” Open source report
Concerns raised 2 Delays in taking a resident to hospital when required View source Failure to accurately record previous falls in falls risk assessments View source
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
Maria Silkin · 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
Maria Silkin fell at a care home on or about 2 September 2014, broke her hip, was taken to hospital a week later, underwent surgery, and subsequently developed pneumonia. The concerns were that her falls history was inaccurately recorded as showing no previous falls and that this contributed to a delay in taking her to hospital.
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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Delays in taking a resident to hospital when required
Wider context from the report “1. During the course of the evidence the Care Home produced a document entitled “Falls Risk Assessment”. In part of that document it was indicated that the “falls history” showed there had been no previous falls whereas I had already heard evidence which was not challenged, to the effect that she had previously fallen numerous times.
2. Because of the above, the action to take her to hospital was, in my opinion, delayed .
” 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 Lodge Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately record previous falls in falls risk assessments
Wider context from the report “1. During the course of the evidence the Care Home produced a document entitled “Falls Risk Assessment”. In part of that document it was indicated that the “falls history” showed there had been no previous falls whereas I had already heard evidence which was not challenged, to the effect that she had previously fallen numerous times.
2. Because of the above, the action to take her to hospital was, in my opinion, delayed.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations