Recipient

Recipient name withheld

First report 16 Apr 2015•Latest report 16 Apr 2015

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

16 Apr2015
West Yorkshire (West)
Concerns raised6
1. Failure of physiotherapy records to contain all relevant details
2. Failure of fall investigations to address preventability and identify relevant contributing factors
3. Lack of assessment of patients’ ability prior to discharge
1. Failure to maintain safe systems of transfer while patients are being transferred
2. Failure to ensure appropriate footwear before patient mobilisation
3. Lack of full training for staff undertaking investigations and preparing investigative reports
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

Jeanne Elsie Summers · 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

Jeanne Elsie Summers was admitted to hospital with an exacerbation of chronic obstructive pulmonary disease and infection, and later suffered an unwitnessed fall while mobilising to the toilet, resulting in an open right ankle fracture. She subsequently developed pneumonia and died on 24 July 2013. Concerns included the absence of a clear mobility assessment before discharge, incomplete physiotherapy records, unsuitable footwear and unsafe transfer practices, and inadequate investigation of the fall.

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 of physiotherapy records to contain all relevant details
Wider context from the report
“(2) During the further readmission on the 7th July 2013 Mrs. Summers was reviewed on a number of occasions by a physiotherapist. At the inquest ████████ Clinical Lead Physiotherapist, provided evidence indicating that the physiotherapy written records did not provide a full record of all relevant details. These notes are reviewed by nursing staff in order to ensure the patient’s safe mobilisation and the preparation of appropriate care plans. I would ask you to consider that additional training and/or direction should be given to the Physiotherapy Department in order to ensure that a full record of all relevant details are made within patients’ records. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure of fall investigations to address preventability and identify relevant contributing factors
Wider context from the report
“(4) At the inquest Matron ████████ gave evidence in respect of an investigation which she undertook in respect of the circumstances surrounding Mrs. Summers’ fall. Matron ████████ indicated in her evidence that she had not received full training with regard to undertaking an investigation and preparing an investigative report. Although in her report she stated that one of the objectives was to consider if the fall could have been prevented, that question was not addressed in her report. When questioned by me she confirmed in evidence that the socks which Mrs. Summers was wearing at the time of her fall and the fact that she was left before she had effectively safely transferred on to the toilet are likely to have been factors which would have caused, or significantly contributed to Mrs. Summers’ fall. Neither of these points were identified in the report. I would request that in future all investigators receive the appropriate training to enable them to undertake a full and appropriate investigation. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Lack of assessment of patients’ ability prior to discharge
Wider context from the report
“(1) The assessment review of Mrs. Summers’ ability prior to her discharge on the 6th July 2013. There is no clear indication that an assessment had been undertaken prior to Mrs. Summers’ discharge on the 6th July 2013. Her condition was such that she required further readmission on the 7th July 2013. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain safe systems of transfer while patients are being transferred
Wider context from the report
“(3) From the evidence presented at the inquest it appears that at the time when Mrs. Summers was mobilising in the early hours of the 14th July 2013 she was wearing her own “fluffy socks”. These were not slipper socks. She was clearly not wearing slippers at the time. In addition the health care assistant who was supervising Mrs Summers did not ensure that Mrs. Summers was seated on the toilet within the toilet cubicle before he left her. I would request you to consider training and guidance to nursing staff to ensure that, firstly, patients are wearing appropriate footwear prior to mobilisation and, secondly, to provide training guidance to staff of safe systems of transfer to ensure that patients are not left whilst in the process of transfer. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure appropriate footwear before patient mobilisation
Wider context from the report
“(3) From the evidence presented at the inquest it appears that at the time when Mrs. Summers was mobilising in the early hours of the 14th July 2013 she was wearing her own “fluffy socks”. These were not slipper socks. She was clearly not wearing slippers at the time. In addition the health care assistant who was supervising Mrs Summers did not ensure that Mrs. Summers was seated on the toilet within the toilet cubicle before he left her. I would request you to consider training and guidance to nursing staff to ensure that, firstly, patients are wearing appropriate footwear prior to mobilisation and, secondly, to provide training guidance to staff of safe systems of transfer to ensure that patients are not left whilst in the process of transfer. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Lack of full training for staff undertaking investigations and preparing investigative reports
Wider context from the report
“(4) At the inquest Matron ████████ gave evidence in respect of an investigation which she undertook in respect of the circumstances surrounding Mrs. Summers’ fall. Matron ████████ indicated in her evidence that she had not received full training with regard to undertaking an investigation and preparing an investigative report. Although in her report she stated that one of the objectives was to consider if the fall could have been prevented, that question was not addressed in her report. When questioned by me she confirmed in evidence that the socks which Mrs. Summers was wearing at the time of her fall and the fact that she was left before she had effectively safely transferred on to the toilet are likely to have been factors which would have caused, or significantly contributed to Mrs. Summers’ fall. Neither of these points were identified in the report. I would request that in future all investigators receive the appropriate training to enable them to undertake a full and appropriate investigation. ”
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 raised6

Failure of physiotherapy records to contain all relevant details

Failure of fall investigations to address preventability and identify relevant contributing factors

Lack of assessment of patients’ ability prior to discharge

Failure to maintain safe systems of transfer while patients are being transferred

Failure to ensure appropriate footwear before patient mobilisation

Lack of full training for staff undertaking investigations and preparing investigative reports