Recipient

Son of the deceased

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First report 22 Nov 2017•Latest report 22 Nov 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 Son of the deceased linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester West

    AI-generated summary

    Kathleen Joan Devine · 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

    Kathleen Joan Devine, a 94-year-old resident of a nursing home with advanced dementia and a history of falls, suffered an unwitnessed fall on 8 June 2017 while attempting to mobilise unsupervised. She sustained a right femur fracture, underwent surgery, and died on 10 June 2017 after her condition deteriorated post-operatively. Concerns included gaps in recorded observations, the removal and unplugging of a falls mat and sensor, and inadequate handover information for agency staff.

    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 Son of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record observations of residents

    Wider context from the report

    “1. The failure of staff to record observations between 6.30am and 8.30am; ”
    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 Son of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate quality and extent of handover instructions to agency staff

    Wider context from the report

    “3. The quality and extent of handover instructions to agency staff; ”
    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 Son of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Removal and unplugging of falls mat and sensor for high-falls-risk residents

    Wider context from the report

    “2. The removal and unplugging of a falls mat and sensor in the room of a resident with high risk falls who was awake, unsupervised and unobserved; ”
    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