Recipient

Recipient name withheld

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First report 21 Sep 2017•Latest report 21 Sep 2017

Recipient record

Reports, concerns and published responses

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 Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Derby and Derbyshire

    AI-generated summary

    Barbara Christine Sturgess · 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

    Barbara Christine Sturgess, who had advanced dementia and was at high risk of falls, sustained a cervical spinal fracture in a fall at her nursing home on 20 May 2017 and died of bronchopneumonia on 8 June 2017. The hospital did not initially inform the nursing home or GP practice of the fracture or necessary care measures; although this was not evidenced to have contributed to her death, it had the potential to adversely affect her wellbeing and could contribute to death in similar cases.

    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 Recipient name withheld; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate confirmed fractures and necessary care measures to relevant care providers

    Wider context from the report

    “The Chesterfield Royal Hospital did not inform the nursing home or the GP practice that Barbara Christine Sturgess had sustained a cervical spinal fracture nor of any necessary measures in her care and treatment. Her daughter attended a fracture clinic appointment with her on 24 May 2017 where a Doctor told the daughter that a fracture had been sustained and that care should be exercised in her management on account of the fracture. It was only on 26 May 2017, as a result of enquiries by the nursing home, that formal confirmation of the fracture was provided by the hospital. Although there was no evidence that the failure of the hospital to properly confirm and advise on the fracture was a factor in Barbara Christine Sturgess’s death this did have the potential to adversely affect her wellbeing. Very importantly if there were to be further similar failings in communication it could be that for some patients this could be a contributory factor in death. ”
    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