Recipient

Mr John Brumfitt (son)

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First report 6 Apr 2021•Latest report 6 Apr 2021

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

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 Mr John Brumfitt (son) linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Sefton, St. Helens and Knowsley

    AI-generated summary

    Pauline BRUMFITT · 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

    Pauline BRUMFITT died on 15 April 2020 after a fall at a care home led to hospital admission and diagnosis of an intracranial bleed. The concerns were that falls risk assessments, prevention measures and referrals were not implemented after her previous falls, and that the incident was not promptly reported or investigated.

    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 Mr John Brumfitt (son); that does not assign responsibility.

    PFD Monitor interpretation

    Failure to report falls-related matters to regulatory bodies

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been. (2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been. (3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence. ”
    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 Mr John Brumfitt (son); that does not assign responsibility.

    PFD Monitor interpretation

    Delayed staff supervision and discussion of falls prevention

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been. (2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been. (3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence. ”
    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 Mr John Brumfitt (son); that does not assign responsibility.

    PFD Monitor interpretation

    Failure to commence a timely investigation of falls-related matters

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been. (2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been. (3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence. ”
    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 Mr John Brumfitt (son); that does not assign responsibility.

    PFD Monitor interpretation

    Failure to apply falls risk assessment and prevention procedures

    Wider context from the report

    “[BRIEF SUMMARY OF MATTERS OF CONCERN] (1) The policies and procedures in existence at the care home pertaining to falls risk assessment and prevention were not applied to Pauline Brumfitt (as stated above) as they should have been. (2) Pauline fell on 3 occasions and the opportunities to assess Pauline’s risks and take appropriate action to prevent further falls were not taken as they should have been. (3) The matter was (given in evidence) not reported to the regulatory bodies and again as given in evidence an investigation had not been commenced at the time of the inquest and staff supervision/discussion re falls prevention had only been commenced in Feb/March 2021, appropriate timely action could have helped (and could still help) to prevent future deaths in similar circumstances where dependent elderly residents are at risk of falling and suffering serious injury/death as a consequence. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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