13 Jun 2025 Valerie HILL · Prevention of Future Deaths report South Wales Central
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Concerns raised 5 Failure of falls-management materials to address preventive risk identification, assessment and documentation View source Lack of an available Falls Prevention Strategy or Policy for resident falls-risk assessments View source Failure to analyse, assess and communicate falls notifications to inform ongoing risk assessment and mitigation View source Failure to obtain Registered Healthcare Professional countersignatures on falls-risk assessment forms View source Lack of effective staff training in falls-risk identification, documentation and mitigation View source See 2 more concerns
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Implement a post-fall summary process to review individual falls and identify ongoing risks.
View source
Action
Implement staff guidance for preventing and managing falls in residential care homes.
View source
Action
Implement a new moving and handling risk assessment form for residential care occupants.
View source
Action
Develop and deliver additional training on the falls guidance, multifactorial assessment and post-fall summary documents.
View source
Action
Implement a multifactorial falls risk assessment for relevant adult services users.
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AI-generated summary
Valerie HILL · 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
Valerie HILL died from pneumonia following a fall that caused a periprosthetic femur fracture, with COPD and frailty of old age contributing. She had remained on the floor for over 14 hours awaiting an ambulance after falling at Ty Bargoed Care Home. The report raised concerns about the identification, documentation and mitigation of falls risks, staff training, completion and oversight of risk assessments, and ambulance handover and patient-flow systems.
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× 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 Merthyr Tydfil County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of falls-management materials to address preventive risk identification, assessment and documentation
Wider context from the report “(3) the material filed with me focuses upon how to move a fallen person/their management post fall, not the identification /assessment/documentation of risk in order to prevent/mitigate the happening of such events .
” 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 Merthyr Tydfil County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of an available Falls Prevention Strategy or Policy for resident falls-risk assessments
Wider context from the report “(5) Your Exhibit KL1 at page 27 references regard being had to Falls Prevention Strategy or Policy – I have received no evidence that MTCBC have such available and in place to inform Care Home’s and their staff in preparation for the completion of a resident’s falls risk assessment
” 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 Merthyr Tydfil County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to analyse, assess and communicate falls notifications to inform ongoing risk assessment and mitigation
Wider context from the report “(6) Whilst I am reassured to an extent in relation to the management and retention of incident & risk assessment documentation created in Ty Bargoed moving forwards, I am unclear as to what action, if any, MTCBC’s Health and Safety Unit take upon receipt of falls notifications (as described in ████████’s evidence) and what, if any, analysis/assessment/communication is undertaken in respect of the same with a view to supplementing the ongoing falls risk assessment and collateral mitigating measures .
” 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 Merthyr Tydfil County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain Registered Healthcare Professional countersignatures on falls-risk assessment forms
Wider context from the report “(4) The exhibits to your statement at KL 1 page 58 appear to suggest that the risk assessment forms ought to be completed/counter-signed by a Registered Healthcare Professional . I received no evidence that such a practice was/is in operation at Ty Bargoed
” 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 Merthyr Tydfil County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of effective staff training in falls-risk identification, documentation and mitigation
Wider context from the report “(2) The material provided at, and post Inquest is absent in evidencing that staff at Ty Bargoed receive any specific, relevant, or effective training in respect of the identification & documenting of falls risks to residents, and the mitigation that can be put in place to reduce those risks . In particular, how the assessments ought to be approached and completed . The material filed, largely relates to employee safety in being able to move and handle residents appropriately. That, I understand is not the aim of the All-Wales NHS Patient Moving and Handling Assessment Documents I was taken to at the Inquest.
” Open source report
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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 Implement a post-fall summary process to review individual falls and identify ongoing risks.
Verbatim wording from the response “9. Additionally, a Post Fall Summary document has also been developed as a means of review and evaluation of any falls sustained by care home residents, to further understand and review risk in general on an ongoing basis. A copy of this document is attached to this witness statement marked “KL 8”.” Source location Response from Merthyr Tydfil County Borough Council
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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 Implement staff guidance for preventing and managing falls in residential care homes.
Verbatim wording from the response “5. Consequent upon the concerns of HM Senior Coroner, however, a number of new documents have now been drafted and have recently been implemented by Merthyr Council in the context of addressing these concerns, moving forwards.” Source location Response from Merthyr Tydfil County Borough Council
Open published response
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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 Implement a new moving and handling risk assessment form for residential care occupants.
Verbatim wording from the response “11. As part of this process, a new Moving and Handling Risk Assessment Form has also been developed and a copy of that new form is attached to this witness statement as “KL 9”. It is anticipated that this new approach to the moving and handling plan will ensure that this document is a “living document” – that is to say – it is continually informed and reviewed by” Source location Response from Merthyr Tydfil County Borough Council
Open published response
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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 Develop and deliver additional training on the falls guidance, multifactorial assessment and post-fall summary documents.
Verbatim wording from the response “13. There will be additional training as to the newly created Prevention and Management of Falls Guidance, the Multifactorial Falls Assessment document and the Post Fall Summary document. Once again, this is an ongoing process, but there is a meeting arranged on Friday 5th September with the Council’s Health and Safety officer and Manual Handling trainer to discuss the development of this training programme.” Source location Response from Merthyr Tydfil County Borough Council
Open published response
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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 Implement a multifactorial falls risk assessment for relevant adult services users.
Verbatim wording from the response “7. A copy of the latest version of this Prevention and Management of Falls guidance document for staff is attached to this witness statement marked “KL 6”.” Source location Response from Merthyr Tydfil County Borough Council
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adult Social Care is responsible for general falls risk through individual care and moving-and-handling plans; Health and Safety addresses environmental or particular risks.
Verbatim wording from the response “24. The (ever present) falls risk associated with elderly persons in a care home setting is primarily the focus of Adult Social Care and needs to be addressed via individual care plans (through Social Services) and moving and handling plans (developed on site – see above), based on appropriate risk assessments. The health and safety team’s principal involvement should be to ensure that if there is an underlying environmental or other particular risk, it is picked up and addressed. Despite the best staff and care, there will be falls from time to time – this is a recognised feature of the care of older and frail persons.” Source location Response from Merthyr Tydfil County Borough Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Registered healthcare professional sign-off is inappropriate in local-authority care homes because such professionals are not routinely available and the requirement is context-specific.
Verbatim wording from the response “17. Firstly, at paragraph (4) HM Senior Coroner identified that the risk assessment forms – according to the All Wales NHS Scheme documentation provided in my initial statement – required to be signed off by a Registered Healthcare Professional. It will be understood by HM Coroner that this documentation was developed, primarily, by the NHS in Wales for use in NHS settings, with regard to the moving and handling of NHS patients. The availability of Registered Healthcare Professionals in those settings is obvious. In a local authority residential care home environment, registered medical healthcare professionals of this type are never routinely available and the “requirement” for sign off of risk assessments by such persons is actually a vestige from the original environment in which these documents were developed (see above).” Source location Response from Merthyr Tydfil County Borough Council
Open published response
27 Sep 2022 Aaron David Edwards · Prevention of Future Deaths report South Wales Central
View report summary
Concerns raised 3 Excessive driver speeds on the Gurnos Ring Road View source Traffic and parked cars around the junction during school pick-up and drop-off times View source Poor visibility at the Goitre Lane and Gurnos Ring Road junction View source
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Aaron David Edwards · 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
Aaron David Edwards, aged 42, died at the scene on 30 August 2020 after his motorcycle collided with a car at a junction in Merthyr Tydfil. The concerns identified were poor visibility at the junction, additional traffic and parked cars near a school during pick-up and drop-off times, and the risk of further deaths if driver speeds were not reduced.
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 Merthyr Tydfil County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Excessive driver speeds on the Gurnos Ring Road
Wider context from the report “(1) The junction of Goitre Lane and the Gurnos Ring Road appears to be dangerous. Visibility is poor for the driver entering the Ring Road due to the bend in the road to the right and the railings protecting a subway below.
(2) Traffic and parked cars around this area at the nearby school Pen-Y-Dre at pick-up and drop off times add to this danger.
(3) Unless changes are made to slow down drivers on the Gurnos Ring Road more deaths may occur.
” 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 Merthyr Tydfil County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Traffic and parked cars around the junction during school pick-up and drop-off times
Wider context from the report “(1) The junction of Goitre Lane and the Gurnos Ring Road appears to be dangerous. Visibility is poor for the driver entering the Ring Road due to the bend in the road to the right and the railings protecting a subway below.
(2) Traffic and parked cars around this area at the nearby school Pen-Y-Dre at pick-up and drop off times add to this danger.
(3) Unless changes are made to slow down drivers on the Gurnos Ring Road more deaths may occur.
” 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 Merthyr Tydfil County Borough Council; that does not assign responsibility.
PFD Monitor interpretation Poor visibility at the Goitre Lane and Gurnos Ring Road junction
Wider context from the report “(1) The junction of Goitre Lane and the Gurnos Ring Road appears to be dangerous. Visibility is poor for the driver entering the Ring Road due to the bend in the road to the right and the railings protecting a subway below.
(2) Traffic and parked cars around this area at the nearby school Pen-Y-Dre at pick-up and drop off times add to this danger.
(3) Unless changes are made to slow down drivers on the Gurnos Ring Road more deaths may occur.
” 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