9 Nov 2018 John Eric Graham · Prevention of Future Deaths report Manchester North
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Concerns raised 1 Lack of routine carbon monoxide detector installation in rented residential accommodation View source
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.
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AI-generated summary
John Eric Graham · 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
John Eric Graham was found dead at his home on 26 February 2018. Although carbon monoxide was initially considered and later excluded from the cause of death, the report raised concern that carbon monoxide detectors were not routinely installed in homes rented by Rochdale Borough Housing Limited, creating a risk of future deaths if unremedied.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of routine carbon monoxide detector installation in rented residential accommodation
Wider context from the report “Carbon monoxide detectors are not routinely installed in residential accommodation rented by Rochdale Borough Housing Limited which, if unremedied, creates a risk of future deaths.
” Open source report
10 Jul 2015 Dorothy McDermott · Prevention of Future Deaths report Manchester North
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Concerns raised 2 Lack of care staff training in the examination and care of pressure sores View source Failure to ensure suitable placements guaranteeing a place of safety for vulnerable individuals View source
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.
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AI-generated summary
Dorothy McDermott · 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
Dorothy McDermott, who was 80 and had been housebound for 2½ years, fell three times at home and was placed in emergency respite care. The care home provided residential but not nursing care, and staff were not trained to examine or care for pressure sores. An inquest concluded that opportunities to examine her sacrum were missed, and she died in hospital after developing a Grade 4 pressure sore and septicaemia.
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How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of care staff training in the examination and care of pressure sores
Wider context from the report “Dorothy McDermott was 80 years old. She had been housebound for 2½ years. She had been diagnosed with a urinary tract infection and was confused. On the 17th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.30pm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18th January. It was envisaged that Mrs McDermott would be reassessed on the 19th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision one of availability with the facility of a ground floor bedroom which had been newly decorated.
Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.
” 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure suitable placements guaranteeing a place of safety for vulnerable individuals
Wider context from the report “Dorothy McDermott was 80 years old. She had been housebound for 2½ years. She had been diagnosed with a urinary tract infection and was confused. On the 17th January 2015, she had fallen three times whilst at home. Paramedics advised a rapid response but they finished at 5.30pm. Mrs McDermott required a place of safety. Following discussions between the Local Authority’s emergency duty team and the out of hours service for the district nursing team, emergency respite care was arranged at the Littleborough Care Home to which Mrs McDermott was conveyed during the early hours of the 18th January. It was envisaged that Mrs McDermott would be reassessed on the 19th January. The Littleborough Care Home offered residential but not nursing care. Care staff at the home were not trained in either the examination for or care of pressure sores. That placement was inappropriate. The rationale for that decision one of availability with the facility of a ground floor bedroom which had been newly decorated.
Whilst appreciating that the decision to procure respite care was made ‘out of hours’ the overriding concern given the extent of Mrs McDermott’s vulnerability should have been to obtain a suitable placement which guaranteed a place of safety. Whilst not wishing to be prescriptive, formal Guidance is required to as to ensure that vulnerable individuals are appropriately placed by the Agencies involved.
” Open source report
2 Jul 2014 Miss Beryl Brinkman · Prevention of Future Deaths report Manchester North
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Concerns raised 2 Parking bays reducing driver visibility when emerging onto the A58 View source Risk of serious harm or death to road users and pedestrians View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Miss Beryl Brinkman · 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
Miss Beryl Brinkman was involved in a serious road traffic collision on 8 January 2014 after emerging from an un-adopted side road onto the A58 Featherstall Road. She suffered catastrophic injuries and died at Royal Oldham Hospital on 10 January 2014. Concerns included the proximity of parked vehicles to the junction, reduced driver visibility, the risk of harm to road users and pedestrians, the appropriateness of the parking bays, and whether the side road should be adopted.
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× 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Parking bays reducing driver visibility when emerging onto the A58
Wider context from the report “1. The proximity of the parking bays to the junction , resulting in a marked reduction of driver visibility when emerging on to the A58/parked cars are present .
” 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Risk of serious harm or death to road users and pedestrians
Wider context from the report “2. The serious risk of harm/death to road users/pedestrians .
” 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 Submit and secure approval for funding to implement the proposed highway safety scheme.
Verbatim wording from the response “A commissioning form was submitted to Pennines Township for funding on the 23rd January and agreed approval on the 18th February. The Network Management Team is currently working on the scheme and the introducing the waiting restrictions.” Source location 2014-0314-Response-by-Rochdale-Borough-Council
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 Review accident history and inspect the junction to assess highway safety issues.
Verbatim wording from the response “As with any serious and fatal collision, it is normal protocol that on receipt of the Police Incident Report the Road Safety Team carries out a full review and site visit to determine any possible highway issues which may have had an impact on the accident.” Source location 2014-0314-Response-by-Rochdale-Borough-Council
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 Implement removal of parking bays and introduction of ‘At Any Time’ waiting restrictions on the A58, including required traffic orders.
Verbatim wording from the response “A commissioning form was submitted to Pennines Township for funding on the 23rd January and agreed approval on the 18th February. The Network Management Team is currently working on the scheme and the introducing the waiting restrictions.” Source location 2014-0314-Response-by-Rochdale-Borough-Council
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 The junction was not considered a priority for action because only one personal injury collision had been recorded there in 12 years.
Verbatim wording from the response “In order to build up a picture of any previous incidents the accident database was reviewed and results showed that there had been only one recorded personal injury accident at this junction in the last 12 years, as such; the site was not on the priority list for action.” Source location 2014-0314-Response-by-Rochdale-Borough-Council
Open published response
10 Mar 2014 Derrick George RIVERS · Prevention of Future Deaths report Manchester North
View report summary
Concerns raised 7 Failure of the drugs administration policy to meet pharmacy requirements for patient and drug identification View source Failure of care home management to identify carers’ non-compliance with drugs administration protocols View source Failure of inspections to identify inadequacies in the drugs policy and drug administration protocol View source Failure to act upon all post-event recommendations in a timely manner View source Incomplete inspection of CQC Outcomes and the drugs administration system View source Lack of care home audit processes View source Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment View source See 4 more concerns
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.
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AI-generated summary
Derrick George RIVERS · 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
Derrick George Rivers, who had been admitted to full-time care after becoming frail and falling, was mistakenly given a 150mg dose of Clozapine intended for another resident. He was admitted to hospital with altered consciousness and confusion, initially improved, then deteriorated and died on 11 July 2013; the inquest found that he died from natural causes to which the Clozapine may have contributed. Concerns included inadequate medication policies and administration protocols, insufficient auditing and inspection, and incomplete implementation of recommendations intended to reduce the risk of medication errors.
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× 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the drugs administration policy to meet pharmacy requirements for patient and drug identification
Wider context from the report “6) That the care home’s policy did not meet the pharmacy requirements in terms of patient and drug identification (pod system) .
” 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of care home management to identify carers’ non-compliance with drugs administration protocols
Wider context from the report “3) That the care home owner and/or manager were purportedly unaware of the fact that carers were not following drugs administration protocols .
” 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of inspections to identify inadequacies in the drugs policy and drug administration protocol
Wider context from the report “1) That the Local Authority and/or CQC, following their recent inspections of the care home, had not noted the inadequacies of the care home’s drugs policy/drug administration protocol .
” 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to act upon all post-event recommendations in a timely manner
Wider context from the report “7) That the care home owner and/or manager did not act upon all recommendations made by ████████ after the event, in a timely manner . Risks therefore remain .
” 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Incomplete inspection of CQC Outcomes and the drugs administration system
Wider context from the report “2) That not all CQC Outcomes were considered at the last inspection , purportedly because they did not have anyone available to inspect and review the drugs administration system at the material time .
” 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of care home audit processes
Wider context from the report “4) That the care home had little, if any, audit processes in place .
” 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 Rochdale Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of the drugs administration protocol to be fit for purpose and specific to the care home environment
Wider context from the report “5) That the care home’s drugs administration protocol was not fit for purpose and was tantamount to a ‘hybrid’ of other policies i.e. it was not specific to the care home environment .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations