Concerns raised 5 Failure to document relevant placement risks and complete required forms View source Inadequate communication of placement risks View source Failure to assess and collate risks to foster carers and other children in the placement View source Lack of foster placement capacity View source Senior decision-making not based on all appropriate information View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 14
Action
Co-produce matching guidance with foster carers and continue improving documentation, recording and approval processes.
Stated plannedThe respondent said that this action was planned when they made their response on 5 September 2025. View source
Action
Use the correct, current placement referral form to share relevant information and risks with foster carers during matching discussions.
Stated completedThe respondent said that this action was complete when they made their response on 5 September 2025. View source
Action
Update and revise children’s case-management forms through a dedicated monthly Systems User Group.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 September 2025. View source
Action
Populate explicit risk-analysis sections in placement referral and matching approval documents for every child requiring a placement.
Stated completedThe respondent said that this action was complete when they made their response on 5 September 2025. View source
Action
Embed foster-carer consultation about placement risk experience through the revised foster-carer communication plan.
Stated completedThe respondent said that this action was complete when they made their response on 5 September 2025. View source
Action
Require senior managers to confirm that placement risks and mitigations have been considered through referral and placement-agreement authorisation.
Stated completedThe respondent said that this action was complete when they made their response on 5 September 2025. View source
Action
Continue enhancing risk-assessment processes and clarify standalone risk-assessment criteria for all placement decision-makers.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 September 2025. View source
Action
Advocate for appropriate national placement sufficiency and engage with Government on the issue.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 September 2025. View source
Action
Deliver the Sufficiency Strategy through residential, fostering, kinship, semi-independent and other placement development to increase appropriate local placement capacity.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 September 2025. View source
Action
Operate the Placements (Fostering) Transformation Board to scrutinise sufficiency, recruitment and retention, and adopt relevant recommendations.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 September 2025. View source
Action
Require senior management approval and signed, child-filed placement referral forms before placements commence, with risks and relevant history shared beforehand.
Stated completedThe respondent said that this action was complete when they made their response on 5 September 2025. View source
Action
Recruit and train foster carers with varied skills and backgrounds to expand appropriate family-based placement capacity.
Stated in progressThe respondent said that this action was in progress when they made their response on 5 September 2025. View source
Action
Operate a dedicated fostering duty worker process to centralise placement information, coordinate matching and support comprehensive information sharing.
Stated completedThe respondent said that this action was complete when they made their response on 5 September 2025. View source
Action
Refine standalone risk-assessment forms and guidance, and routinely apply the clarified threshold for children posing risks to themselves or others.
Stated completedThe respondent said that this action was complete when they made their response on 5 September 2025. View source See 11 more actions
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AI-generated summary
Marcia Grant · 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
Marcia Grant, a foster carer, died on 5 April 2023 after suffering significant chest injuries when a vehicle driven by her foster child collided with her. The report identified concerns about a shortage of placements, incomplete documentation and communication of risks, and inadequate risk assessment when placing the child with the Grant family.
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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to document relevant placement risks and complete required forms
Wider context from the report “(2) Documentation and communication. Both the lack of documentation recording all the relevant risks , failure to complete forms and the lack of adequate communication of the risks in this matter led to a child being placed with a family where numerous individuals considered this was an inappropriate placement. Senior decision making was not based on all the appropriate information identifying there are inadequate systems and processes.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate communication of placement risks
Wider context from the report “(2) Documentation and communication. Both the lack of documentation recording all the relevant risks, failure to complete forms and the lack of adequate communication of the risks in this matter led to a child being placed with a family where numerous individuals considered this was an inappropriate placement. Senior decision making was not based on all the appropriate information identifying there are inadequate systems and processes.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to assess and collate risks to foster carers and other children in the placement
Wider context from the report “(3) Risk Assessment. Evidence was heard about the risks posed by the Child but no evidence that the risk to the foster carers or the other child in their care had been considered or assessed . Again there was lack of documentation and no formal risk assessment document or collated risk profile for all individuals to allow proper consideration of risks.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of foster placement capacity
Wider context from the report “(1) Lack of placements. The lack of foster placements placed significant strain on the Local Authority to consider creative solutions to try and avoid an unauthorised placement. This led to an unsuitable placement being accepted. I was informed the shortage of placements is a both a local and a national issue and therefore both Rotherham Metropolitan Borough Council and the Minister for the Department for Education are asked to consider this concern.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Senior decision-making not based on all appropriate information
Wider context from the report “(2) Documentation and communication. Both the lack of documentation recording all the relevant risks, failure to complete forms and the lack of adequate communication of the risks in this matter led to a child being placed with a family where numerous individuals considered this was an inappropriate placement. Senior decision making was not based on all the appropriate information identifying there are inadequate systems and processes .
” 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 Co-produce matching guidance with foster carers and continue improving documentation, recording and approval processes.
Verbatim wording from the response “• Continue to make improvements to documentation, recording and approval processes and co-produce matching guidance with our foster carers” Source location Response from Rotherham Metropolitan Borough Council
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 Use the correct, current placement referral form to share relevant information and risks with foster carers during matching discussions.
Verbatim wording from the response “At the time of the initial placement being required for Child X, limited information was known about his background and needs. The initial placement referral form was brief and did not contain all relevant information. While the placement referral form was repeatedly updated over the short period Child X was in care with RMBC, we could not determine which placement referral form had been shared with Mrs Grant during the initial matching discussions due to the version control of documents. There were however a number of conversations with Mrs Grant about Child X. Mrs Grant had also taken steps to ensure that she knew where Child X was at all times and that she had locked away knives to ensure he could not access these. RMBC acknowledge that the storage and version control of documents required improvement and had already taken steps to address this.” Source location Response from Rotherham Metropolitan Borough Council
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 Update and revise children’s case-management forms through a dedicated monthly Systems User Group.
Verbatim wording from the response “There have been challenges around pre-populated forms, within the children’s case management system, which RMBC acknowledge can be lengthy and cumbersome. Sections within certain forms were repetitive and led to social workers only completing relevant sections of forms, which leaves many sections blank. A dedicated Systems User Group within RMBC meets monthly to focus on work required to update and revise forms within the children’s case management system.” Source location Response from Rotherham Metropolitan Borough Council
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 Populate explicit risk-analysis sections in placement referral and matching approval documents for every child requiring a placement.
Verbatim wording from the response “Following Mrs Grant’s tragic death, various specific changes have been made to ensure that the Council delivers the best possible services to foster carers and children and young people.” Source location Response from Rotherham Metropolitan Borough Council
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 Embed foster-carer consultation about placement risk experience through the revised foster-carer communication plan.
Verbatim wording from the response “Foster carers will also continue to be consulted around their experience of risk when children have been placed to ensure that the Local Authority learns via the lived experience of carers and children. RMBC has recently revised the foster carer communication plan to ensure that this is embedded within practice.” Source location Response from Rotherham Metropolitan Borough Council
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 Require senior managers to confirm that placement risks and mitigations have been considered through referral and placement-agreement authorisation.
Verbatim wording from the response “The authorisation levels of placement referral forms and placement agreements ensure that Senior Managers are responsible for ensuring all matters of risk have been considered, alongside mitigation of these risks.” Source location Response from Rotherham Metropolitan Borough Council
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 Continue enhancing risk-assessment processes and clarify standalone risk-assessment criteria for all placement decision-makers.
Verbatim wording from the response “• Continue to enhance risk assessment processes and ensure criteria for standalone risk assessments for placements are clear to all involved.” Source location Response from Rotherham Metropolitan Borough Council
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 Advocate for appropriate national placement sufficiency and engage with Government on the issue.
Verbatim wording from the response “The complexity of these placements remains one of the most difficult decision-making processes that the Council is involved in. We will continue to work with our staff, children and foster carers to deliver these services as effectively as possible to meet the needs of all involved. We will also continue to advocate for appropriate national” Source location Response from Rotherham Metropolitan Borough Council
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 Deliver the Sufficiency Strategy through residential, fostering, kinship, semi-independent and other placement development to increase appropriate local placement capacity.
Verbatim wording from the response “Development of new children’s residential provision, along with foster care, third party placements, semi-independent provisions, and other family-based placements, aims to provide a mixed economy of arrangements, which will seek to effectively meet Rotherham’s statutory duties, outlined in the Sufficiency Strategy.” Source location Response from Rotherham Metropolitan Borough Council
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 Operate the Placements (Fostering) Transformation Board to scrutinise sufficiency, recruitment and retention, and adopt relevant recommendations.
Verbatim wording from the response “Following a report to the Children in Care Sufficiency Board in May 2025 reviewing the current fostering recruitment strategy, it was agreed a time limited Placements (Fostering) Transformation Board should be established.” Source location Response from Rotherham Metropolitan Borough Council
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 Require senior management approval and signed, child-filed placement referral forms before placements commence, with risks and relevant history shared beforehand.
Verbatim wording from the response “Schemes of delegation and approval processes were also revised during 2023 to ensure that information about children requiring a placement is approved by a senior manager to ensure quality and consistency. Mitigation of risk and relevant history is considered and shared with prospective carers and providers prior to matching discussions taking place.” Source location Response from Rotherham Metropolitan Borough Council
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 Recruit and train foster carers with varied skills and backgrounds to expand appropriate family-based placement capacity.
Verbatim wording from the response “RMBC have maintained a cohort of experienced foster carers in the Borough and continue to recruit new foster carers with a range of skills.” Source location Response from Rotherham Metropolitan Borough Council
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 Operate a dedicated fostering duty worker process to centralise placement information, coordinate matching and support comprehensive information sharing.
Verbatim wording from the response “In 2023, a dedicated fostering duty worker was appointed to manage and share information with in-house foster carers about children needing a placement. This process ensures that information is held in one place and the duty worker has in depth knowledge of available carers and their skill set, to promote effective matching with children. The duty role co-ordinates matching discussions and information sharing between supervising social workers, foster carers themselves and allocated social workers for children to ensure a comprehensive overview of each child requiring a placement. RMBC has ensured that all social workers within the service understand and follow the process.” Source location Response from Rotherham Metropolitan Borough Council
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 Refine standalone risk-assessment forms and guidance, and routinely apply the clarified threshold for children posing risks to themselves or others.
Verbatim wording from the response “Standalone risk assessment forms have been maintained and refined for children and young people who may present with high risks, and guidance has been revised since the inquest to ensure that the threshold for standalone risk assessments is clear and that this practice is routinely implemented where children are deemed to pose a risk to themselves or others.” Source location Response from Rotherham Metropolitan Borough Council
Open published response
×
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 Child X was not assessed as posing high risk, and no evidence indicated risks would increase to require a standalone assessment.
Verbatim wording from the response “At the time of Child X’s placement, the Local Authority had worked on the premise that risks, when these are determined to be high, are considered within a more in-depth assessment. When placed, Child X was not deemed to pose a high risk of harm to himself, or others and no evidence was presented which indicated that the risks identified would increase and so a stand-alone risk assessment had not been completed. As acknowledged above, the initial placement referral form did not contain all the known risks about Child X. As concerns developed about the other young person in placement, this was considered and acted upon by RMBC, including the provision of a significant support package to help mitigate risk to him and an acceptance by the whole professional network that Child X’s placement could only be of very short duration.” Source location Response from Rotherham Metropolitan Borough Council
Open published response
Concerns raised 2 Road verges capable of launching out-of-control vehicles onto or over the Armco barrier View source Pooling water on the carriageway View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Jonathan Edward Michael Sellman · 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
Jonathan Edward Michael Sellman sustained fatal injuries when his vehicle lost control on the A630 Sheffield Parkway on 28 March 2016, apparently after encountering standing water, and collided with a barrier and lamp post before tumbling down an embankment. The substantive concerns were water pooling on the carriageway and the condition of the verges, which might cause an out-of-control vehicle to be pushed upwards and land on or over the Armco barrier.
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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Road verges capable of launching out-of-control vehicles onto or over the Armco barrier
Wider context from the report “(2) The state of the verges is such that a car might be pushed upwards on leaving the road out of control, landing on or over the Armco barrier.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Pooling water on the carriageway
Wider context from the report “(1) Water appears to be pooling on the carriageway of this fast and busy road, notwithstanding that the Local Authority consider the drainage to have been broadly operative at the relevant time.
” 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 Implement dash-cam monitoring by having a design technician drive the Parkway during heavy rain.
Verbatim wording from the response “(iv) it has purchased a dash cam and implemented a system whereby a design technician drives along the Parkway to monitor the situation during periods of heavy rain.” Source location 2016-0395-Response-by-Rotherham-Metropolitan-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 Survey the highway drainage system at the relevant location to assess its suitability.
Verbatim wording from the response “Rotherham MBC takes Mr Dorries’ concerns extremely seriously and has taken a number of steps since the accident to meet these concerns including the following:” Source location 2016-0395-Response-by-Rotherham-Metropolitan-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 Add a drainage supervisor to monthly driven highway inspections.
Verbatim wording from the response “(iii) when undertaking its regular inspections of the highway by way of monthly driven inspections, the highway inspector is now accompanied by a drainage supervisor;” Source location 2016-0395-Response-by-Rotherham-Metropolitan-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 Investigations concluded that the road geometry and drainage system do not create a risk of standing water or pooling on the carriageway.
Verbatim wording from the response “(i) the A630 was built in the 1960s and the geometry of this highway is appropriate and adheres to relevant construction standards;” Source location 2016-0395-Response-by-Rotherham-Metropolitan-Borough-Council
Open published response
×
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 Established highway maintenance, drainage cleansing, inspection and public-reporting arrangements were considered adequate and exceeded national standards.
Verbatim wording from the response “(iv) Rotherham has long established procedures for the maintenance of the highway at the accident locus, which are in accordance with and in fact exceed National standards and which may be summarised as follows:-” Source location 2016-0395-Response-by-Rotherham-Metropolitan-Borough-Council
Open published response
Concerns raised 6 Insufficient staff training in following the head injury protocol View source Lack of procedures for closer scrutiny and monitoring of residents at continuing high risk of serious injury View source Failure of initial safeguarding referral screening to be sufficiently detailed and objective View source Lack of suitable alternative residential placement for residents with high nursing needs View source Insufficient staff training in recognising indicators and triggers for social worker input View source Insufficient staff training in record keeping View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Phyllis Broomhead · 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
Phyllis Broomhead, who had dementia and lived at Lord Hardy Court EMI Residential Home, suffered repeated falls, including three significant falls requiring hospitalisation. On 9 June 2013 she fell from her bed while trying to reach the toilet, sustained a head injury and died later that day from a traumatic left-sided subdural haemorrhage. Concerns included incomplete implementation of measures, staff training and record keeping, safeguarding screening, and the lack of closer monitoring or alternative placement for residents at high risk of serious injury.
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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in following the head injury protocol
Wider context from the report “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to:
i. the head injury protocol, how this should be followed and the importance of doing so.
ii. record keeping.
iii. indicators and triggers to seek social worker input.
(2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of procedures for closer scrutiny and monitoring of residents at continuing high risk of serious injury
Wider context from the report “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to:
i. the head injury protocol, how this should be followed and the importance of doing so.
ii. record keeping.
iii. indicators and triggers to seek social worker input.
(2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure of initial safeguarding referral screening to be sufficiently detailed and objective
Wider context from the report “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to:
i. the head injury protocol, how this should be followed and the importance of doing so.
ii. record keeping.
iii. indicators and triggers to seek social worker input.
(2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Lack of suitable alternative residential placement for residents with high nursing needs
Wider context from the report “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to:
i. the head injury protocol, how this should be followed and the importance of doing so.
ii. record keeping.
iii. indicators and triggers to seek social worker input.
(2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in recognising indicators and triggers for social worker input
Wider context from the report “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to:
i. the head injury protocol, how this should be followed and the importance of doing so.
ii. record keeping.
iii. indicators and triggers to seek social worker input.
(2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training in record keeping
Wider context from the report “(1) Staff employed at Lord Hardy Court EMI Residential Home require further training with regard to:
i. the head injury protocol, how this should be followed and the importance of doing so.
ii. record keeping.
iii. indicators and triggers to seek social worker input.
(2) With regard to the Safeguarding team, subject to the impact of any subsequent legislation, the importance of ensuring that any initial screening process following a referral is sufficiently detailed and objective to facilitate the making of safe, sound and informed decisions with regard to any future action which might be indicated or indeed before exiting the process. Furthermore, I heard evidence that there were three types of home available; care homes, EMI care homes and nursing homes. For residents who are clearly continuing to be at high risk of serious injury, as was the case here, consideration should be given to introducing or expanding any local procedures or protocols to ensure closer scrutiny and monitoring of such residents' progress. It seemed that although Mrs Broomhead was identified as being of high risk of falls, as it was felt that she neededn't amount to nursing needs there was no alternative but for her to remain in a care home.
” 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 Re-engineer safeguarding documentation to capture the customer journey and provide detailed screening guidance for informed exit decisions.
Verbatim wording from the response “Work Completed
Safeguarding documentation has been re-engineered to be Care Act compliant and to ensure the customer journey is captured and recorded. More detailed guidance and standard practice to confirm what documents have been screened, dates spoken to during the screening stage to enable the decision maker to make informed decisions before exiting.” Source location 2015-0290-Response-by-Rotherham-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 Involve registered managers in reviewing complex, high-risk safeguarding referrals with safeguarding managers.
Verbatim wording from the response “Work Outstanding
Registered Managers to be formally involved with the “reviewing” complex referrals with Safeguarding Managers, taking meetings to take place to consider the ongoing risks for “high risk failures”.” Source location 2015-0290-Response-by-Rotherham-Borough-Council
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 Deliver record-keeping training and review care records through meetings, site visits and remedial-action follow-up.
Verbatim wording from the response “Record keeping and the importance of accurate documentation have always been paramount to RMBC, however further training embedded in training programmes, team meetings, supervisors’ meetings, and site visits are carried out by Regulation Officers. Care Managers and samples of care records are reviewed. From this the Service Manager is informed of any remedial actions that are required.” Source location 2015-0290-Response-by-Rotherham-Borough-Council
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 Implement and embed head-injury protocols through staff training, supervision, team meetings, shift sign-offs and personal development reviews.
Verbatim wording from the response “Work Completed
Head injury policy is in place, developed by health care professionals that support all care homes with necessary interventions and document following a fall. New protocol following a fall has also been put in place (developed by registered health professionals). This has been shared with RSMBC residential services, Shift supervisors check and sign off each shift to ensure that all actions of each shift have been completed. In-house training has been implemented. The new protocols have been embedded in team meetings, individual supervision and Personal Development Reviews (PDRs).” Source location 2015-0290-Response-by-Rotherham-Borough-Council
Open published response
14 Mar 2014 Gavin Anthony ROBERTS · Prevention of Future Deaths report Rotherham
View report summary
Concerns raised 2 Failure to set speed restrictions appropriate to the safe negotiation speed of the bend and approach to the bridge View source Inadequate warning signs at the bend and bridge approach View source
Responses linked to these concerns
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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
Gavin Anthony ROBERTS · 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
Gavin Anthony Roberts died in a fatal collision while riding his motorcycle on Hollings Lane on 24 October 2013. He lost control after overtaking on a bend and collided with an oncoming vehicle; significantly underinflated tyres were a major factor. The concerns related to the 60 mph speed restriction being higher than the safe speed for the bend, its increase from 40 mph on the approach, and the apparent inadequacy of warning signs given the number of incidents at the location.
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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Failure to set speed restrictions appropriate to the safe negotiation speed of the bend and approach to the bridge
Wider context from the report “(1) The current speed restriction of 60 mph is higher than the maximum speed at which
The bend can safely be negotiated.
(2) The speed restriction actually increases from 40 mph to 60 mph on the approach to the bridge.
(3) The warning signs appear to be inadequate in the presence
of (1) and (2) above given the number of recorded incidents at this location.
” 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 Rotherham Borough Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate warning signs at the bend and bridge approach
Wider context from the report “(1) The current speed restriction of 60 mph is higher than the maximum speed at which
The bend can safely be negotiated.
(2) The speed restriction actually increases from 40 mph to 60 mph on the approach to the bridge.
(3) The warning signs appear to be inadequate in the presence
of (1) and (2) above given the number of recorded incidents at this location.
” 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