Recipient

Stanley Park

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First report 27 Nov 2023•Latest report 27 Nov 2023

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. 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 Stanley Park linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to “Stanley Park Care Centre”, a former name of Stanley Park.

    County Durham and Darlington

    AI-generated summary

    Margaret AUSTIN · 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

    Margaret Austin died at Stanley Park Care Home on 17 September 2023, following an unwitnessed fall from her bed on 1 July 2023 that caused a pubic rami fracture and contributed to her overall decline. Concerns included incomplete and discrepant documentation about managing her high falls risk, lack of evidence that the risk management plan was reviewed as her risks changed or after falls, and outstanding falls-risk training for most care-home staff at the date of the inquest.

    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 Stanley Park; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of falls risk training for care home staff

    Wider context from the report

    “3. Staff training in relation to falls risk remained outstanding at the date of the Inquest for the majority (3/4) of staff at the care home. ”
    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 Stanley Park; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate and inconsistent documentation of falls risk management

    Wider context from the report

    “1. The deceased was known to be at high risk of falls and the documentation in relation to how to manage that known high risk of falls was not comprehensive and contained significant discrepancies as to what should, in fact, be in place, and contained no rationale for why further measures which may have been considered appropriate were not in situ or considered appropriate or necessary. ”
    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 Stanley Park; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to review risk management plans when risks change or after falls

    Wider context from the report

    “2. There was no evidence that the risk management plan was reviewed as the deceased's risks changed nor in the aftermath of documented falls. ”
    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