Concerns raised 7 Delegation of investigations without terms of reference View source Investigation conclusions based on assumptions View source Lack of detailed organisational investigation guidance View source Failure to explore all relevant investigation scenarios View source Lack of routine investigation training for managers View source Delays in receipt of provider-led report requests resulting in investigations without all relevant issues known View source Failure of senior management involvement in investigations View source See 4 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. 4
Action
Strengthen serious-incident investigations through senior-management notification, Director of Care sign-off, root-cause analysis, and evidence-based conclusions.
View source
Action
Provide all managers with investigation-skills training from Bromley Adult Safeguarding.
View source
Action
Provide all managers with investigation-skills training from Croner.
View source
Action
Train all managers on the Accident and Incident Reporting, Serious Incident Notification, and Root Cause Analysis policies and procedures.
View source See 1 more action
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AI-generated summary
James Collier SIDDONS · 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
James Collier Siddons, who had very severe frailty and multiple co-morbidities, was admitted to hospital after sustaining a fractured left humerus at a nursing home. He subsequently developed aspiration pneumonia and pyelonephritis and died suddenly from sepsis on 31 January 2022. Concerns were raised that the investigation into his fracture was flawed, that the organisation lacked detailed investigation guidance and routine training, and that relevant issues were not communicated promptly by the local authority.
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 Mills Family Limited; that does not assign responsibility.
PFD Monitor interpretation Delegation of investigations without terms of reference
Wider context from the report “1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
” 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 Mills Family Limited; that does not assign responsibility.
PFD Monitor interpretation Investigation conclusions based on assumptions
Wider context from the report “1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
” 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 Mills Family Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of detailed organisational investigation guidance
Wider context from the report “2. Mills have a policy setting out a broad overview of the principles of investigation but no detailed guidance on how an investigation should be conducted within its organisation
” 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 Mills Family Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to explore all relevant investigation scenarios
Wider context from the report “1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
” 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 Mills Family Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of routine investigation training for managers
Wider context from the report “3. There is no routine investigation training for managers
” 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 Mills Family Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in receipt of provider-led report requests resulting in investigations without all relevant issues known
Wider context from the report “4. Mills did not receive the request for the provider led report from LBB until almost a month after the incident. The investigation was started promptly but had to be conducted without Mills being satisfied that all the relevant issues were 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 Mills Family Limited; that does not assign responsibility.
PFD Monitor interpretation Failure of senior management involvement in investigations
Wider context from the report “1. The investigation into the circumstances of Mr Siddons suffering a fracture was flawed such that lessons that might prevent an incident which could result in a future death have not been learnt
a. It failed to explore all the scenarios that might have accounted for fracture.
b. It was in part delegated to a deputy manager without terms of reference
c. Mills Family senior management was not involved
d. The investigation’s conclusions were based on assumptions
” 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 Strengthen serious-incident investigations through senior-management notification, Director of Care sign-off, root-cause analysis, and evidence-based conclusions.
Verbatim wording from the response “1. To re-emphasise to all managers and deputy managers that all serious incidents should be notified to the senior management team in line with company policies. Further, re-emphasise that input from the Director of Care, Mandy Finn, should be sought before any investigation report or serious incident report is finalised and circulated.” Source location Response from Mills Family Ltd
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 Provide all managers with investigation-skills training from Bromley Adult Safeguarding.
Verbatim wording from the response “All managers to receive training to improve investigation skills from:” Source location Response from Mills Family Ltd
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 Provide all managers with investigation-skills training from Croner.
Verbatim wording from the response “All managers to receive training to improve investigation skills from:” Source location Response from Mills Family Ltd
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 Train all managers on the Accident and Incident Reporting, Serious Incident Notification, and Root Cause Analysis policies and procedures.
Verbatim wording from the response “2. All managers to receive training on new policies regarding:” Source location Response from Mills Family Ltd
Open published response
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