Recipient

Rch Care Homes Limited

First report 1 Apr 2016•Latest report 1 Apr 2016

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: 100%
Concerns addressed: 3
Stated actions: 7

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.

100%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Rch Care Homes Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

1 Apr2016
Mid Kent and Medway
Concerns raised3
1. Failure to fully engage cot-side retaining buttons
2. Failure to assess injuries after a significant uncontrolled fall before repositioning the patient
3. Failure to use safe post-fall handling for patients with possible head or cervical spine injury
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Retrain all care-delivering staff in moving and handling through e-learning and competency-based workbooks.
  Stated in progress
2. Action
  Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.
  Stated completed
3. Action
  Audit bedrails through maintenance checks and management rechecks to confirm secure locking with an audible click.
  Stated completed
1. Action
  Re-educate staff in bedrail use through direct supervision to ensure locking mechanisms are properly engaged.
  Stated completed
2. Action
  Provide daily-meeting health and safety briefings reinforcing the risks of unsecured bedrails, recorded in meeting minutes and supervision records.
  Stated completed
AI-generated summary

Lilian Hursell · 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

Lilian Hursell died at Pembury Hospital on 6 July 2015 from pneumonia contracted following reduced mobility associated with unstable fractured cervical vertebrae after a fall from bed at Maidstone Care Centre. The concerns included bedrails not being securely engaged and the handling of Lilian Hursell after a significant uncontrolled fall before the extent of her injuries had been assessed.

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 Rch Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to fully engage cot-side retaining buttons
Wider context from the report
“(1) The mechanism to hold the cotsides (bedrails) in a vertical position comprise a retaining button in a sliding vertical rail which engages with a corresponding hole in a static rail. Whilst this mechanism operates safely when the mechanism is properly engaged which is established by an audible click, staff at the care home had experienced occasions when the cotsides retaining button had not been fully engaged when the cotside had been raised to prevent a resident falling from the bed rendering the cotside unstable and at risk of lowering inadvertently. ”
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 Rch Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to assess injuries after a significant uncontrolled fall before repositioning the patient
Wider context from the report
“(2) Nursing and healthcare staff moved a patient onto her back and placed a pillow under her head when the patient had suffered a significant uncontrolled fall onto her face and the extent of her injuries had not been assessed. It was known at the time that this happened that she had suffered a head trauma as she had a bleeding injury to her forehead, she had however additionally suffered a subdural haematoma and had fractures to her cervical vertebra ”
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 Rch Care Homes Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to use safe post-fall handling for patients with possible head or cervical spine injury
Wider context from the report
“(2) Nursing and healthcare staff moved a patient onto her back and placed a pillow under her head when the patient had suffered a significant uncontrolled fall onto her face and the extent of her injuries had not been assessed. It was known at the time that this happened that she had suffered a head trauma as she had a bleeding injury to her forehead, she had however additionally suffered a subdural haematoma and had fractures to her cervical vertebra ”
Open source report
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
Retrain all care-delivering staff in moving and handling through e-learning and competency-based workbooks.

Verbatim wording from the response
“• A programme of moving and handling re-training has been commenced and will be completed by the 1st June 2016, this is carried out in the blended approach of e-learning and via competency based workbooks for all staff delivering care.”

Source location
Hursell-Response
Page 1 · response
Published 1 April 2016
Open published response
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
Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.

Verbatim wording from the response
“• All staff have been advised that following a fall no person should be moved until a full assessment by a suitably trained person has been carried out.”

Source location
Hursell-Response
Page 2 · response
Published 1 April 2016
Open published response
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
Audit bedrails through maintenance checks and management rechecks to confirm secure locking with an audible click.

Verbatim wording from the response
“• A thorough system of bedrail audits has been introduced to ensure all bedrails lock with an audible click into the safety bracket. This entails an audit via the maintenance operative to check for safety and security which is then rechecked by the home manager.”

Source location
Hursell-Response
Page 1 · response
Published 1 April 2016
Open published response
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
Re-educate staff in bedrail use through direct supervision to ensure locking mechanisms are properly engaged.

Verbatim wording from the response
“• Staff have been re-educated in bed rail use in order to ensure the locking mechanism is properly engaged. This was done via a process of direct supervisions.”

Source location
Hursell-Response
Page 1 · response
Published 1 April 2016
Open published response
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
Provide daily-meeting health and safety briefings reinforcing the risks of unsecured bedrails, recorded in meeting minutes and supervision records.

Verbatim wording from the response
“• Staff have received health and safety briefings in daily meetings to reiterate the potential dangers of not ensuring bed rails are locked in position. This is recorded via staff meeting minutes and direct supervisions.”

Source location
Hursell-Response
Page 2 · response
Published 1 April 2016
Open published response

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 raised3

Failure to fully engage cot-side retaining buttons

Failure to assess injuries after a significant uncontrolled fall before repositioning the patient

Failure to use safe post-fall handling for patients with possible head or cervical spine injury

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.5

Actions described in response 5