St Giles

Private and voluntary organisations · Domiciliary care provider

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First report 17 Nov 2017•Latest report 12 Dec 2017

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: 2
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

Statements from St Giles linked to the concerns in each report. Select any concern, action or position to view the source wording.

12 Dec2017
Birmingham and Solihull
Concerns raised12
1. Failure to undertake an internal investigation and learn lessons from the case
2. Failure to provide the nursing home with information about monitoring a high risk plaster cast
3. Lack of continuity of care
1. Lack of a care plan for management and monitoring of the plaster cast
2. Failure to document signs of infection
3. Lack of further staff training on plaster casts
4. Failure to adequately check the plaster cast for signs of infection
5. Inadequate discharge planning
6. Lack of clear guidelines for managing high risk fractures treated conservatively
7. Failure to arrange an outpatient appointment within 3 weeks of discharge
8. Failure to arrange weekly post-discharge x-rays to monitor fracture alignment
9. Failure to document pus on the plaster cast
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Francis Robert Beech · 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

Francis Robert Beech had a conservatively treated right ankle fracture and was discharged to a nursing home, where monitoring and care planning for his plaster cast were not arranged. Infection signs were present by 1 July 2017 but were not investigated promptly, and he later developed a severely infected compound fracture and pressure sores before dying from bronchopneumonia contributed to by chronic obstructive pulmonary disease and the infected fracture site.

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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake an internal investigation and learn lessons from the case
Wider context from the report
“7. Failing to undertake an internal investigation to ensure lessons were learnt from this case. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide the nursing home with information about monitoring a high risk plaster cast
Wider context from the report
“5. Failing to provide any information to the nursing home about the need to monitor the plaster cast and that it was high risk. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Lack of continuity of care
Wider context from the report
“2. Lack of continuity of care. Each week a different consultant took over his care. This led to a lack of continuity and inadequate discharge planning. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Lack of a care plan for management and monitoring of the plaster cast
Wider context from the report
“1. Failing to have any care plan for the management and monitoring of his plaster cast. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Failure to document signs of infection
Wider context from the report
“3. Failing to document any signs of infection ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Lack of further staff training on plaster casts
Wider context from the report
“4. There has been no further training for staff on plaster casts. The nursing home should review the training needs for staff on the care and management of plaster casts. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Failure to adequately check the plaster cast for signs of infection
Wider context from the report
“2. Failing to adequately check the plaster cast for signs of infection ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Inadequate discharge planning
Wider context from the report
“2. Lack of continuity of care. Each week a different consultant took over his care. This led to a lack of continuity and inadequate discharge planning. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Lack of clear guidelines for managing high risk fractures treated conservatively
Wider context from the report
“1. Lack of clear guidelines regarding the management of high risk fractures treated conservatively. I heard evidence that this was a high risk fracture as there were sharp edges and little skin over the ankle area. The deceased required regular monitoring as a result. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Failure to arrange an outpatient appointment within 3 weeks of discharge
Wider context from the report
“4. Failing to arrange an outpatient appointment within 3 weeks of discharge. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Failure to arrange weekly post-discharge x-rays to monitor fracture alignment
Wider context from the report
“3. Failing to arrange weekly x-rays after discharge to check for fracture alignment and to monitor the fracture. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Failure to document pus on the plaster cast
Wider context from the report
“6. Failing to document pus on the cast when he attended for a hip x-ray on 01/07/17. ”
Open source report
17 Nov2017
Birmingham and Solihull
Concerns raised2
1. Use of pressure sore risk tools with opposing score interpretations
2. Failure of the pressure sore risk tool to account for existing lesions
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mildred Joan Griffiths · 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

Mildred Joan Griffiths fell at home in May 2017, sustained a femur fracture, developed a deteriorating sacral pressure sore, and died after collapsing in the early hours of 03/08/17. The report raised concerns that differing pressure-sore risk assessment tools could cause confusion and that the Braden Score might underestimate risk because it did not account for existing lesions.

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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Use of pressure sore risk tools with opposing score interpretations
Wider context from the report
“1. The pressure sore risk tool used in the home is the Braden Score. The community Healthcare Trust use the Walsall score – which is nationally recognised. I note the Braden score does not take into account any existing lesion when calculating the risk which means it may under estimate the risk. In addition the Braden score calculates in an opposite way to the Walsall score – thus a low score is high risk in the Braden score, but low risk in the Walsall score. This can lead to confusion between professionals and the home should consider changing to the Walsall score. ”
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 St Giles; that does not assign responsibility.
PFD Monitor interpretation
Failure of the pressure sore risk tool to account for existing lesions
Wider context from the report
“1. The pressure sore risk tool used in the home is the Braden Score. The community Healthcare Trust use the Walsall score – which is nationally recognised. I note the Braden score does not take into account any existing lesion when calculating the risk which means it may under estimate the risk. In addition the Braden score calculates in an opposite way to the Walsall score – thus a low score is high risk in the Braden score, but low risk in the Walsall score. This can lead to confusion between professionals and the home should consider changing to the Walsall score. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised12

Failure to undertake an internal investigation and learn lessons from the case

Failure to provide the nursing home with information about monitoring a high risk plaster cast

Lack of continuity of care

Lack of a care plan for management and monitoring of the plaster cast

Failure to document signs of infection

Lack of further staff training on plaster casts

Failure to adequately check the plaster cast for signs of infection

Inadequate discharge planning

Lack of clear guidelines for managing high risk fractures treated conservatively

Failure to arrange an outpatient appointment within 3 weeks of discharge

Failure to arrange weekly post-discharge x-rays to monitor fracture alignment

Failure to document pus on the plaster cast

Concerns raised2

Use of pressure sore risk tools with opposing score interpretations

Failure of the pressure sore risk tool to account for existing lesions