12 Dec 2017 Francis Robert Beech · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 12 Failure to undertake an internal investigation and learn lessons from the case View source Failure to provide the nursing home with information about monitoring a high risk plaster cast View source Lack of continuity of care View source Lack of a care plan for management and monitoring of the plaster cast View source Failure to document signs of infection View source Lack of further staff training on plaster casts View source Failure to adequately check the plaster cast for signs of infection View source Inadequate discharge planning View source Lack of clear guidelines for managing high risk fractures treated conservatively View source Failure to arrange an outpatient appointment within 3 weeks of discharge View source Failure to arrange weekly post-discharge x-rays to monitor fracture alignment View source Failure to document pus on the plaster cast View source See 9 more concerns
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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.
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× 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 Nov 2017 Mildred Joan Griffiths · Prevention of Future Deaths report Birmingham and Solihull
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Concerns raised 2 Use of pressure sore risk tools with opposing score interpretations View source Failure of the pressure sore risk tool to account for existing lesions View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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.
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× 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations