1 Oct 2021 Stephen Martin Verrall · Prevention of Future Deaths report South London
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Concerns raised 3 Failure to routinely check window restrictors during regulatory inspections View source Unavailability of weekend reception monitoring to prevent residents following visitors through the exit door View source Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk View source
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 5
Action
Advertise for a weekend receptionist to monitor the door at weekends.
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Action
Position a staff member by the side gate during fire drills and disable the gate's exit code.
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Action
Station the administrator in reception during normal working hours to monitor the entrance and secure door closure.
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Action
Restrict visitor access codes and require staff accompaniment for entry and exit.
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Action
Advise staff about unauthorised exits and require secure door closure and vigilance around reception.
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AI-generated summary
Stephen Martin Verrall · 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
Stephen Martin Verrall fell from the window of his first-floor room at St John’s Nursing Home and died from his injuries two days later. Concerns included an inadequate window restrictor, lack of a window-maintenance risk assessment, unrestricted windows remaining years later, and risks of residents leaving the home unaccompanied.
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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 Johns Nursing Home Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to routinely check window restrictors during regulatory inspections
Wider context from the report “(1) Care Quality Commission – I was informed that CQC did not routinely check window restrictors on inspections . I was told that it was the responsibility of providers to comply with regulatory requirements in this regard. Whilst that is uncontroversial, the death in this case, and the fact that there remained unrestricted windows in August 2021 nearly four years after this death, demonstrated that checks by the regulator are required . Responsive checks after incidents are not sufficient to prevent deaths .
” 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 Johns Nursing Home Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of weekend reception monitoring to prevent residents following visitors through the exit door
Wider context from the report “(2) St John’s Nursing Home – I heard that Stephen had managed to leave the home unaccompanied on several occasions. The opportunity to do so for those without capacity and without the ability to assess risk poses a risk to their lives. I was told that the reception is not manned on the weekends and there is a risk that residents may follow visitors through the door when they leave .
” 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 Johns Nursing Home Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to prevent unaccompanied exit by residents without capacity or ability to assess risk
Wider context from the report “(2) St John’s Nursing Home – I heard that Stephen had managed to leave the home unaccompanied on several occasions . The opportunity to do so for those without capacity and without the ability to assess risk poses a risk to their lives . I was told that the reception is not manned on the weekends and there is a risk that residents may follow visitors through the door when they leave.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advertise for a weekend receptionist to monitor the door at weekends.
Verbatim wording from the response “iv. We are advertising for a weekend receptionist to ensure going forwards the door is monitored at weekends. In the interim, all staff are ensuring the door is closed securely behind them;” Source location 2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Position a staff member by the side gate during fire drills and disable the gate's exit code.
Verbatim wording from the response “v. We ensure that when there is a fire drill a member of staff stands by the side gate. This gate is key coded for exit, which is disabled during fire drills. The member of staff ensures residents do not leave the premises;” Source location 2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Station the administrator in reception during normal working hours to monitor the entrance and secure door closure.
Verbatim wording from the response “iii. During normal working hours, the administrator is situated in the reception area and ensures staff securely closes the door behind them;” Source location 2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Restrict visitor access codes and require staff accompaniment for entry and exit.
Verbatim wording from the response “i. Visitors are not given the key code, which is changed regularly, for entry or exit so are accompanied by a member of staff;” Source location 2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Advise staff about unauthorised exits and require secure door closure and vigilance around reception.
Verbatim wording from the response “ii. All staff have been advised of the potential problem of residents leaving through the front door. When letting visitors in and out of the building staff ensure the door is securely closed behind them and they have been advised to be alert around the reception area during the course of their working day/night;” Source location 2021-0336-Response-from-St-Johns-Nursing-Home-Ltd_Published
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations