South Molton Community Hospital

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First report 21 Jan 2015•Latest report 21 Jan 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 South Molton Community Hospital linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Exeter and Greater Devon

    AI-generated summary

    Robert Alan JONES · 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 Alan JONES suffered multiple falls following a stroke and later deteriorated, dying at South Molton Community Hospital on 1 April 2014. The inquest recorded accidental death, with acute on chronic subdural haematoma and multiple falls due to cerebrovascular accidents. Concerns included inadequate communication about the total number of falls, use of an out-of-date post-falls checklist, and incomplete or incorrectly recorded neurological observations.

    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 South Molton Community Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate the patient's total number of falls to all visiting staff

    Wider context from the report

    “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”
    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 South Molton Community Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record neurological observations correctly and at the minimum recommended frequency

    Wider context from the report

    “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”
    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 South Molton Community Hospital; that does not assign responsibility.

    PFD Monitor interpretation

    Use of an out-of-date post-falls checklist lacking required neurological observation details

    Wider context from the report

    “(1) There was no evidence of communication to ensure that all staff including the different GPs visiting, were aware of the total number of falls the patient has sustained. An out of date post falls checklist was used which does not include specific details of the frequency in duration of neurological observations as recommended by NICE, where head injury has occurred and can or cannot be ruled out and the patient did not always have his neurological observations recorded as per the minimum recommended. They were not always recorded correctly on the observation charts. ”
    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