Recipient

Pinderfields Hospital

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First report 2 Aug 2021•Latest report 2 Aug 2021

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 Pinderfields Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Yorkshire Eastern

    AI-generated summary

    Mary Ann LINCOLN · 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

    Mary Ann LINCOLN was admitted to Pinderfields General Hospital on 18 May 2020 and was discovered deceased on the floor of her room on 21 May 2020, with an open fracture of the tibia and fibula. The concerns identified included inadequate overnight checks for vulnerable patients at risk of falls and weaknesses in the circulation and understanding of the bedrails policy.

    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 Pinderfields Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of guidance for assessing vulnerable patients for overnight checks

    Wider context from the report

    “(1) During evidence it became apparent that there is no guidance or policy with regard to checks on patients overnight (who are not subject to NEWS, turning etc). Mrs Lincoln was put in to bed at around 2130 and only checked once in the night despite being in hospital, having a history of falls and knowledge of the fact she needed the toilet overnight. Although she had previously used the call buzzer she was also known to mobilise herself. She was not discovered until 0630, and then only because someone noticed as they passed her door. She had lain on the floor for some time, with an open fracture. The hospital conducted a serious incident review in which it recommended the checks policy should be reviewed. It appears it was reviewed but no changes were made. Evidence had been heard that previous rounding checks were deemed inappropriate and therefore no further action was required. Therefore there is no policy or guidance with regard to people who are vulnerable, a falls risk and known to get up in the night (for any reason) to be further assessed for checks overnight. ”
    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 Pinderfields Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure the bedrails policy is circulated and understood by staff responsible for implementing it

    Wider context from the report

    “(2) There is a bedrails policy in place, the author of the SI report found that it appeared to be comprehensive. During evidence however the staff responsible for implementing its use were either unaware of it (it appears it is not circulated to HCA’s), or find it confusing. There is obviously a void between producing a policy and ensuring it is circulated and understood by all concerned. ”
    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