Concerns raised 7 Failure to make an appropriate decision on the level of supervision View source Failure to account for sedative medication changes in falls risk assessment View source Failure to scale up care and prompt urgent review when problems arise View source Failure to determine whether falls should be recorded in the Accident Record View source Delay in seeking mental health practitioner advice for progressive agitation View source Failure to specify a date for future review View source Failure to trigger serious or untoward incident review following repeated falls View source See 4 more 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
KENNETH SMITH · 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
Kenneth Smith, who had cognitive impairment and was at high risk of falls, died on 9 November 2020 after falling at a care home and developing acute-on-chronic subdural haematomas. The report raised concerns about reducing his supervision, failing to set a review date, inadequate escalation of care after further falls, and insufficient consideration of medication and mental-health factors in assessing his falls risk.
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 Shannon Court Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to make an appropriate decision on the level of supervision
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” 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 Shannon Court Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to account for sedative medication changes in falls risk assessment
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” 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 Shannon Court Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to scale up care and prompt urgent review when problems arise
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” 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 Shannon Court Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to determine whether falls should be recorded in the Accident Record
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls , resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” 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 Shannon Court Care Centre; that does not assign responsibility.
PFD Monitor interpretation Delay in seeking mental health practitioner advice for progressive agitation
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” 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 Shannon Court Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to specify a date for future review
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review . It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” 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 Shannon Court Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to trigger serious or untoward incident review following repeated falls
Wider context from the report “After a proposed re-assessment of the falls risk posed by the deceased on the 22nd of October 2020 the 14-day period expired on the 22nd and 29th of October established that the deceased was to suffer 6 falls between the 22nd and 29th of October 2020.
Two of these falls took place on the 22nd of October 2020 – the same date of the reduction in the level of care being offered.
The evidence from the care home indicated that there was no date that had been given for a future review. It was also accepted that there was no action taken to consider whether any fall or falls resulted in the Accident Record including no action taken on the 29th of October 2020 when the deceased suffered two falls, resulting in tears and a head injury.
Additionally, the evidence established that on release from hospital to the care home on the 6th of October 2020, the discharge clinicians had stopped the prescription of Trazodone due to its known sedative qualities. There was no evidence of this (as part of the falls risk assessment) being taken into account by carers adequately, or at all.
Care staff had only escalated concerns over the deceased's progressive agitation to a general practitioner on 30th of October 2020. This had resulted in a referral to the Older Persons' Mental Health Team. There was no evidence as to why further advice from a mental health practitioner was not sought earlier, or as part of the risk assessment on the 22nd of October 2020.
The nature and quality of the care received by the deceased between the 22nd and 31st of October 2020 reveal the following concerns:
1. The decision to reduce the level of supervision was suboptimal, incorrect and unlawful.
2. The failure to consider and specify a review date;
3. The lack of appropriate scaling up of care to meet identified problems or issues with the reduced level of care, with no prompt to act on urgent review.
4. Care plan guidance, whilst not triggered, was serious or untoward incidents review by the care home, the CCG, or local authority;
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations