Recipient

Son of the deceased

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First report 16 Apr 2015•Latest report 16 Apr 2015

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. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Robert Henry Payne · 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

    Robert Henry Payne was admitted to hospital after falling at home and fracturing his left neck of femur. While in hospital, he experienced repeated falls, including one that dislocated the repaired hip and necessitated further surgery; the reported concerns included falls despite high-risk assessments and a ward transfer without an apparent transfer document, followed by a fall that was not witnessed. He later developed an infected surgical wound and died on 13 July 2014.

    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

    Unwitnessed patient falls

    Wider context from the report

    “(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20th May 2014. (2) He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed. ”
    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 prevent falls among patients identified as being at high risk of falling

    Wider context from the report

    “(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20th May 2014. (2) He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed. ”
    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 complete transfer documentation between wards

    Wider context from the report

    “(1) Despite repeated falls risk assessments identifying the deceased as being at high risk of falling he fell on no less than four occasions whilst in hospital which necessitated further surgery as a direct consequence of the fall on the 20th May 2014. (2) He was transferred between wards at 1am in the morning in circumstances in which it appears no transfer document was completed and fell in circumstances in which the fall was not witnessed. ”
    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