Recipient

Patrick Stead Hospital

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First report 3 Oct 2018•Latest report 3 Oct 2018

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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 Patrick Stead Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Suffolk

    AI-generated summary

    Brian Alban Frost · 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

    Brian Alban Frost, a 92-year-old retired Roman Catholic priest who lived alone, died after an unwitnessed fall at home on 30 June 2018, sustaining severe head injuries. The report raised concerns about loose kitchen floor tiles presenting a trip hazard and about the inadequacy of welfare checks and health-and-safety risk assessments for retired clergy living in diocesan properties.

    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 Patrick Stead Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake health and safety or risk assessments during welfare visits

    Wider context from the report

    “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017. 6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. 7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. 8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken. 9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's 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 Patrick Stead Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Reliance on residents or informal third parties to identify hazards and request accommodation repairs

    Wider context from the report

    “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017. 6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. 7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. 8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken. 9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's 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 Patrick Stead Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of independent assessment for health and safety risks in grace and favour accommodation

    Wider context from the report

    “5. It was heard in evidence that the diocese had a system of visits in place from the Clergy Welfare Officer and, if the retired priest was subject to a ‘covenant of care’ a Safeguarding Coordinator. Details of visits to Canon Frost’s home were recorded as taking place in October 2010, December 2010, January 2011, July 2011, May 2012, January 2013, April 2014, August 2014, July 2016 and October 2017. 6. In reports compiled in relation to these visits no mention is made of any health and safety or risk assessment activity being undertaken. 7. A note from the October 2017 visit (11 months prior to Canon Frost’s death) provides details of a recent fall in which Canon Frost fractured his hip, the fact he now used a walking frame and that his bedroom had been moved down stairs (following a visit from the local NHS Community Health Team). The property manager offered Canon Frost a visit from the Clergy Welfare Coordinator but this was declined. 8. Despite identifying major factors regarding Canon Frost’s mobility and increasing frailty, again no mention is made of any health and safety or risk assessment activity being undertaken. 9. Giving the nature of the residents of these properties there is a degree of certainty that other ‘grace and favour’ residents will lose (or have already lost) the physical ability or the mental capacity to maintain their accommodation in a safe condition. On the evidence heard the system of welfare checks was not sufficiently robust and there was no independent assessment for health and safety risks. It was apparent that the current system required the resident themselves, a family member or some other third party to raise such concerns when the fabric of the building is deteriorating. The resident themselves would then need to request for the work to be undertaken. 10. Dependant on the personal circumstance of each retired member of the clergy this system appears flawed, as it relies solely on the resident retaining the mental capacity and/or the physical ability to identify that a hazard exists and then make their own request for repairs. Without doubt, the welfare system currently in place failed to identify and remedy the fact that an obvious and serious trip hazard risk was present in Canon Frost's 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 Patrick Stead Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Unsafe loose and displaced flooring creating a trip hazard in occupied accommodation

    Wider context from the report

    “2. Photographic evidence produced during the inquest of Canon Frost clearly demonstrates that the floor tiles in his kitchen had become loose and were no longer fastened to the floor. One of the floor tiles is completely out of position and the others appear to be loose with large gaps between the tiles themselves. In his witness statement ████████ commented “the flooring where Canon Frost would have fallen was very loose and could have been a trip hazard for Canon Frost.” 3. Considering his frailty, the fact he lived alone and the medical conditions suffered by Canon Frost, on the available evidence this flooring was clearly not safe by any measure. In evidence it was heard that the flooring is sufficiently porous that it will need to be replaced prior to the re-occupation/sale of the property. ”
    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