Concerns raised 4 Lack of formal systems for checking residents after fire alarm activations View source Failure to effectively cascade care processes, protocols and expectations to staff providing care to residents View source Failure to effectively cascade care processes, protocols and expectations to staff View source Lack of formal systems for checking residents after fire alarm activations View source See 1 more concern
Responses linked to these concerns
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AI-generated summary
Margaret Aitchison · 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
Margaret Aitchison, a resident of Broom Lane Care home, accessed a fire door and fell down an unheated stairwell after a fire alarm activation, sustaining traumatic injuries and being found hypothermic; she died from her injuries. The report raised concerns about inadequate resident and fire-exit checks after alarm activations and whether updated procedures had been effectively communicated and implemented.
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 Pristine Care Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of formal systems for checking residents after fire alarm activations
Wider context from the report “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations , is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for:
1. Further training of senior staff.
2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations.
3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits.
” 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 Pristine Care Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively cascade care processes, protocols and expectations to staff providing care to residents
Wider context from the report “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes . Accordingly, I invite you to consider the following and in particular whether there is a need for:
1. Further training of senior staff.
2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations.
3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits.
” 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 Pristine Care Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to effectively cascade care processes, protocols and expectations to staff
Wider context from the report “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations, is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes . Accordingly, I invite you to consider the following and in particular whether there is a need for:
1. Further training of senior staff.
2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations.
3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits.
” 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 Pristine Care Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of formal systems for checking residents after fire alarm activations
Wider context from the report “The evidence from a care worker who was at the home at the relevant time, and remains a care worker at the home, that there are still no formal systems for checking of residents after fire alarm activations , is at odds with the evidence I heard from the care manager that there had been comprehensive changes and a training programme implemented. I am concerned that the processes, protocols and expectations have not been effectively cascaded to those providing care to residents in homes. Accordingly, I invite you to consider the following and in particular whether there is a need for:
1. Further training of senior staff.
2. A requirement for senior staff to each put in place clear processes for staff to respond to fire alarm activations.
3. Training of carers, and any other relevant staff members, in terms of checking resident safety and fire door exits.
” 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 Cascade lessons learned to sister services across the organisation’s portfolio.
Verbatim wording from the response “As always the ethos of the organisation is ensuring the safety of our residents is paramount and the lessons learnt have been cascaded to our sister services within the portfolio.” Source location Response from Pristine Care Group
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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 Implement revised care processes and protocols addressing identified shortfalls.
Verbatim wording from the response “I can confirm and agree with the statement made by my colleague ████████ when she gave evidence that the processes and protocols put in place after reviewing the original items are definitely in place (some of which were with immediate effect) and as an organisation we are confident as we can be that any identified shortfalls have been addressed and the auditing duties carried out by the senior management team on a regular basis should highlight any discrepancies in the future. I can also confirm that a CQC inspector visited the care home only this week to review the protocols after receiving notification from your office and she was more than happy with improvements made.” Source location Response from Pristine Care Group
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 Conduct regular senior-management audits to identify discrepancies in care processes and protocols.
Verbatim wording from the response “I can confirm and agree with the statement made by my colleague ████████ when she gave evidence that the processes and protocols put in place after reviewing the original items are definitely in place (some of which were with immediate effect) and as an organisation we are confident as we can be that any identified shortfalls have been addressed and the auditing duties carried out by the senior management team on a regular basis should highlight any discrepancies in the future. I can also confirm that a CQC inspector visited the care home only this week to review the protocols after receiving notification from your office and she was more than happy with improvements made.” Source location Response from Pristine Care Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing protocols, addressed shortfalls and regular senior-management audits are considered sufficient to identify and prevent future discrepancies.
Verbatim wording from the response “I can confirm and agree with the statement made by my colleague ████████ when she gave evidence that the processes and protocols put in place after reviewing the original items are definitely in place (some of which were with immediate effect) and as an organisation we are confident as we can be that any identified shortfalls have been addressed and the auditing duties carried out by the senior management team on a regular basis should highlight any discrepancies in the future. I can also confirm that a CQC inspector visited the care home only this week to review the protocols after receiving notification from your office and she was more than happy with improvements made.” Source location Response from Pristine Care Group
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations