Recipient

Pindy Enterprises Limited

First report 6 Mar 2015•Latest report 6 Mar 2015

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Pindy Enterprises Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

6 Mar2015
Manchester West
Concerns raised7
1. Insufficient alarm audibility in the clinician’s room
2. Lack of Agency staff training in documentation, record keeping and risk assessment procedures
3. Reliance on Agency staff as the sole trained nurse and senior member of staff during night incidents
1. Omissions in documentation and record keeping of falls and changes in residents’ condition
2. Failure to review falls risk assessments and refer recurrent falls back to the Falls Service
3. Lack of procedures for reviewing risk assessments after falls or significant changes in residents’ condition
4. Failure of alarm signals to distinguish falls-sensor activation from handheld-buzzer requests for assistance
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Emmeline Hampson · 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

Emmeline Hampson died in hospital on 6 November 2014 after a fall at her nursing home caused a subdural haematoma and intracerebral bleeding. The concerns included repeated falls without review of her falls risk assessment or referral back to the Falls Service, inadequate procedures and record keeping, shortcomings in alarm audibility and differentiation, and insufficient training of agency staff.

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 Pindy Enterprises Limited; that does not assign responsibility.
PFD Monitor interpretation
Insufficient alarm audibility in the clinician’s room
Wider context from the report
“Furthermore the alarms activated in the resident’s room and an office used by staff. The office used by staff includes a clinician’s room where staff prepared medications but the volume of the alarm in the office was insufficient to be heard in the clinician’s room, so that a member of staff working in the clinician’s room would not be able to hear the alarm. ”
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 Pindy Enterprises Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of Agency staff training in documentation, record keeping and risk assessment procedures
Wider context from the report
“vi. The evidence at the Inquest in relation to the fall on the 29th October 2014 was given by a trained nurse employed by an Agency who did not appear to be familiar with the documentation and record keeping particularly relating to risk assessments and there did not appear to be any training of Agency Staff in relation to those procedures. ”
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 Pindy Enterprises Limited; that does not assign responsibility.
PFD Monitor interpretation
Reliance on Agency staff as the sole trained nurse and senior member of staff during night incidents
Wider context from the report
“The regular use of Agency staff was of particular concern bearing in mind that the trained nurse from the Agency would be the senior member of staff and the only trained nurse to deal with incidents during the night. ”
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 Pindy Enterprises Limited; that does not assign responsibility.
PFD Monitor interpretation
Omissions in documentation and record keeping of falls and changes in residents’ condition
Wider context from the report
“iv. There were omissions in the documentation and record keeping at the Nursing Home particularly in relation to falls, and changes in Mrs Hampson’s condition, which were witnessed by members of her family on a daily basis. ”
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 Pindy Enterprises Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to review falls risk assessments and refer recurrent falls back to the Falls Service
Wider context from the report
“ii. From the 4th October 2014 there were five falls including the fall on the 4th October 2014 and culminating in the fall on the 29th October 2014. There was no review of the falls risk assessment and no referral back to the Falls Service following any one of the falls between the 4th October 2014 and the 29th October 2014 even though Mrs Hampson’s condition had changed and there were recurrent falls. ”
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 Pindy Enterprises Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of procedures for reviewing risk assessments after falls or significant changes in residents’ condition
Wider context from the report
“iii. There were no procedures in place at the Nursing Home in relation to the review of risk assessments after a fall or after an obvious and significant change in a resident’s condition. ”
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 Pindy Enterprises Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure of alarm signals to distinguish falls-sensor activation from handheld-buzzer requests for assistance
Wider context from the report
“v. The alarm in relation to the activation of the falls sensor placed in Mrs Hampson’s room and the handheld buzzer available to Mrs Hampson were the same so that it was not possible to distinguish between activation of the falls sensor arising from Mrs Hampson getting out of bed and Mrs Hampson requesting assistance from a carer, which may simply relate to a request for a drink. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised7

Insufficient alarm audibility in the clinician’s room

Lack of Agency staff training in documentation, record keeping and risk assessment procedures

Reliance on Agency staff as the sole trained nurse and senior member of staff during night incidents

Omissions in documentation and record keeping of falls and changes in residents’ condition

Failure to review falls risk assessments and refer recurrent falls back to the Falls Service

Lack of procedures for reviewing risk assessments after falls or significant changes in residents’ condition

Failure of alarm signals to distinguish falls-sensor activation from handheld-buzzer requests for assistance