Son of the deceased

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First report 19 Mar 2015•Latest report 19 Mar 2015

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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. Cardiff and Vale of Glamorgan

    AI-generated summary

    Elsie May Hayward · 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

    Elsie May Hayward was admitted to hospital after a fall at home and was being treated for sepsis. During her admission, she sustained four falls, including a likely fall from her bed that caused a head injury and subdural haematoma; her condition deteriorated and she died three days later. Concerns included overstretched staffing, inadequate post-head-injury observations, and omissions and inconsistencies in clinical records and communication.

    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

    Insufficient staffing capacity for safe patient oversight

    Wider context from the report

    “1. On the 7th January 2015 medical staff were having to care for 50% more patients over what is generally considered to be safe staffed patient ratio. The evidence showed that the team was significantly overstretched and as a result were not able to oversee the care to this lady. Because of the pressures on the team it is likely that there were deficiencies in the care afforded to her which may have contributed to her repeated falls. ”
    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

    Failure to maintain complete and consistent nursing and clinical records

    Wider context from the report

    “3. There were extensive omissions in the note taking and a clear inconsistency between the “nursing notes” and “clinical notes” resulting in confusion and breakdown of communication between the nursing staff and the medical team. ”
    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

    Failure to undertake nursing observations in accordance with required procedures and guidance

    Wider context from the report

    “2. Despite clear guidance and directive the nursing observations on the deceased following her head injury were not undertaken in accordance with the Health Boards procedure and the N.I.C.E. national guidance. ”
    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

Data last updated 7 September 2026