Concerns raised 2 Failure to ensure access to GP and community mental health services for people released from prison View source Lack of accommodation for people released from prison View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Darren Clifford Docherty · 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
Mr Darren Clifford Docherty was released from HMP Stoke Heath without accommodation and was subsequently found hanging from a tree on 10 August 2023. The report raised concern that people released from prison without accommodation may be unable to access GP and community mental health services.
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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure access to GP and community mental health services for people released from prison
Wider context from the report “1. That when people are released from prison they do so, on many occasions, with no accommodation. Those that need GP access and community mental health services are unable to access them in these circumstances .
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of accommodation for people released from prison
Wider context from the report “1. That when people are released from prison they do so, on many occasions, with no accommodation . Those that need GP access and community mental health services are unable to access them in these circumstances.
” 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 Work with prison-service partners to maintain a clear referral pathway explaining housing options before release, beyond the Duty to Refer mechanism.
Verbatim wording from the response “3. We will continue to work with partners across the prison service to ensure a clear referral pathway is in place above and beyond the Duty to Refer mechanism so that everyone has a better understanding of the housing options available before a prisoner is released, however, it must be recognised that this is unlikely to result in a firm offer of accommodation for everyone especially those that have no priority need;” Source location Response from Stoke on Trent City Council
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 Work with prisons through established mechanisms, including pre-release panels, to maintain robust procedures for people released at risk of homelessness.
Verbatim wording from the response “2. We will continue to work with prisons to ensure robust procedures are in place for those being released at risk of homelessness through already established mechanisms such as the pre-release panel, a joint meeting between prison based accommodation staff and the Council’s dedicated Housing Needs” Source location Response from Stoke on Trent City Council
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 Work with health and social-care colleagues to link people released without accommodation to homeless healthcare, mental-health nursing and wider homelessness support services.
Verbatim wording from the response “4. We will continue to work with colleagues in health and social care to support individuals released from prison with no accommodation to access GP and community mental health services by ensuring they are aware of and linked into the existing Homeless Healthcare Service and Rough Sleeping Mental Health nurse and the wider support available through Hanley Connects, the City Council’s Homelessness Hub and the Rough Sleeper Outreach Service.” Source location Response from Stoke on Trent City Council
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 Review the Duty to Refer process to ensure referrals receive a response within three days.
Verbatim wording from the response “1. We have already completed a review of the Duty to Refer process to ensure all referrals receive a response within 3 days of receipt so that prisoners due for release and their representatives in the prison service are aware they need to either approach the Housing Solutions Service within office hours or the Emergency Duty Team outside of office hours if they are released with no accommodation secured on the day of their release;” Source location Response from Stoke on Trent City Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Council cannot offer immediate accommodation to everyone leaving custody because legal duties, accommodation shortages and resource constraints limit provision.
Verbatim wording from the response “Despite the `Duty to Refer,` there is no absolute duty on a local housing authority to provide accommodation for all households or individuals who present as homeless. It should be acknowledged and noted that most local authorities, including Stoke-on-Trent, will provide accommodation for certain non-priority households at their” Source location Response from Stoke on Trent City Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Central Government should be separately asked to consider legal duties for interim accommodation and funding for local authorities.
Verbatim wording from the response “We as a Local Authority take our responsibilities to those leaving custody extremely seriously but regrettably do not have sufficient accommodation or resources available to make an offer of immediate accommodation at the point of presentation to everyone regardless of priority need. It is therefore suggested that the Coroner may wish to separately consider making a Report to Central Government in terms of the legal duties that apply to offers of interim accommodation, especially for those leaving custody and the allocation of funding to Local Authorities to provide this.” Source location Response from Stoke on Trent City Council
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The Council cannot directly address access to GP or community mental health services because it does not commission those services.
Verbatim wording from the response “Whilst the local authority does not commission GP or community mental health services and is therefore not in a position to directly address these concerns, it is aware that homelessness should not be a barrier to registration with a GP.” Source location Response from Stoke on Trent City Council
Open published response
Concerns raised 1 Failure to review traffic measures around the school 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
Minaal Salam · 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
Minaal Salam, aged 5, was struck by a Volkswagen Touran outside her primary school on Waterside Drive on 1 April 2022 and died at the scene. The concern was that traffic management around the school should be investigated, as inadequate traffic measures could pose a risk of future deaths.
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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to review traffic measures around the school
Wider context from the report “During the course of the inquest I heard evidence to suggest that investigations into the traffic is managed around this school should be done to prevent future occurrences. In light of this, I have a concern that, if the traffic measures are not looked at , there is a risk of future deaths
” Open source report
Concerns raised 2 Lack of a plan to make residents aware of the “Stay Put” fire policy View source Failure to ensure residents’ awareness of the “Stay Put” fire policy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 12
Action
Undertake more in-depth questioning of Stay Put Block tenants and use the resulting feedback to inform the fire-safety communication strategy.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Develop a fire-safety and Stay Put video and question-and-answer materials for residents with different learning styles.
Stated in progressThe respondent said that this action was in progress when they made their response on 28 June 2021. View source
Action
Review the frequency of fire-safety and Stay Put communications to leaseholders.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Engage tenants through Tenant Board participation, community events, leaseholder newsletters, councillor surgeries and promoted fire-safety services.
Stated completedThe respondent said that this action was complete when they made their response on 28 June 2021. View source
Action
Provide, translate, display and periodically redistribute Fire Safety Notices explaining the Stay Put Policy to residents and leaseholders.
Stated completedThe respondent said that this action was complete when they made their response on 28 June 2021. View source
Action
Communicate and verify understanding of the Stay Put Policy during tenancy visits using trained Housing Officers, scripted questions, declarations and documented checklists.
Stated completedThe respondent said that this action was complete when they made their response on 28 June 2021. View source
Action
Post Fire Safety Notices through all leaseholder properties’ letterboxes and explain leaseholders’ responsibility to inform and educate sub-tenants.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Require Housing Officers conducting Tenancy Audit Visits to complete enhanced training on communicating with tenants whose first language is not English.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Use proactive telephone calls to discuss fire safety, check tenants’ understanding and update relevant records.
Stated completedThe respondent said that this action was complete when they made their response on 28 June 2021. View source
Action
Explore the effectiveness of displaying additional communal notices explaining that Fire Safety Notices can be requested in other languages.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Consider increasing targeted digital communications conveying the Stay Put Policy to residents in Stay Put Blocks.
Stated plannedThe respondent said that this action was planned when they made their response on 28 June 2021. View source
Action
Provide accessible fire-safety communication through translation, imagery, disability-adapted communication, interpreters and coordinated support for tenants requiring additional assistance.
Stated completedThe respondent said that this action was complete when they made their response on 28 June 2021. View source See 9 more actions
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AI-generated summary
Zainab Adam Bargo Hashim and Tafaoul Abdullilia Abdulkarim · 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
Zainab Adam Bargo Hashim died on 2 October 2017 and Tafaoul Abdullilia Abdulkarim died two days later after inhaling fire fumes while attempting to flee a fire through the communal area of their block of flats. The report identified concern that residents were unaware of the council’s “Stay Put” policy and that the policy’s communication had not been changed after the incident, creating a risk of future deaths.
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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of a plan to make residents aware of the “Stay Put” fire policy
Wider context from the report “During the inquest Stoke-on-Trent City Council gave evidence to the effect that, within the properties that they own (they have some 19000 properties), if the properties are blocks of flats, there is a “Stay Put” policy in place. Residents, so long as the fire is not within their property, should stay in their flats, alert the appropriate emergency service, and wait for help.
It became apparent during the course of the inquest that no resident at the Ringland Close block of flats knew of the existence of this policy. Stoke-on-Trent City Council gave evidence to the effect that to communicate this policy to their residents they do so in exactly the same way that they had before the fire at Ringland Close . There are fire notices in the communal areas of the flats and in September 2017, a tenant newsletter was posted through all letterboxes at relevant blocks of flats. This newsletter reiterated the “Stay Put” policy.
During this particular incident no residents had stayed within their property. No residents were aware of the “Stay Put” policy. Evidence was heard that, had Zainab and Tafaoul, stayed within ████████ the two deaths would not have occurred. Stoke-on-Trent City Council gave evidence that, since the fire, they have not changed the way the policy is communicated to residents of their properties .
Therefore, the lack of awareness of a policy in place, and lack of plan to make residents aware , in the event of a fire leads me to conclude that there is a risk of future deaths occurring.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure residents’ awareness of the “Stay Put” fire policy
Wider context from the report “During the inquest Stoke-on-Trent City Council gave evidence to the effect that, within the properties that they own (they have some 19000 properties), if the properties are blocks of flats, there is a “Stay Put” policy in place. Residents, so long as the fire is not within their property, should stay in their flats, alert the appropriate emergency service, and wait for help.
It became apparent during the course of the inquest that no resident at the Ringland Close block of flats knew of the existence of this policy . Stoke-on-Trent City Council gave evidence to the effect that to communicate this policy to their residents they do so in exactly the same way that they had before the fire at Ringland Close. There are fire notices in the communal areas of the flats and in September 2017, a tenant newsletter was posted through all letterboxes at relevant blocks of flats. This newsletter reiterated the “Stay Put” policy.
During this particular incident no residents had stayed within their property. No residents were aware of the “Stay Put” policy . Evidence was heard that, had Zainab and Tafaoul, stayed within ████████ the two deaths would not have occurred. Stoke-on-Trent City Council gave evidence that, since the fire, they have not changed the way the policy is communicated to residents of their properties.
Therefore, the lack of awareness of a policy in place , and lack of plan to make residents aware, in the event of a fire leads me to conclude that there is a risk of future deaths occurring.
” 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 Undertake more in-depth questioning of Stay Put Block tenants and use the resulting feedback to inform the fire-safety communication strategy.
Verbatim wording from the response “More in depth questioning will be undertaken of tenants in Stay Put Blocks, of their understanding of the Stay Put Policy. Feedback obtained will be used to inform the Council’s communication strategy around fire safety going forward.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Develop a fire-safety and Stay Put video and question-and-answer materials for residents with different learning styles.
Verbatim wording from the response “We are also in the formative stages of developing a video on fire safety and Stay Put and a series of questions and answers to help to communicate the Stay Put Policy to residents with different types of learning styles. It is intended that the video will be watched during the application process for Council housing by those who have been offered a Council property and be available to all tenants.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Review the frequency of fire-safety and Stay Put communications to leaseholders.
Verbatim wording from the response “The Council will review the frequency of how it communicates with leaseholders around fire safety and Stay Put.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Engage tenants through Tenant Board participation, community events, leaseholder newsletters, councillor surgeries and promoted fire-safety services.
Verbatim wording from the response “The Council has a Tenant Board which represents the diverse demographic residing in Council owned and managed social housing in Stoke-on-Trent, with the purpose of giving tenants a voice on key aspects of housing management. The seven Tenant Board Members are involved in how the Stay Put Policy is communicated and recently participated in trialling the Proactive Calls.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Provide, translate, display and periodically redistribute Fire Safety Notices explaining the Stay Put Policy to residents and leaseholders.
Verbatim wording from the response “All residents in Stay Put Blocks receive a copy of the Fire Safety Notice (Appendix A) produced in partnership with Staffordshire Fire and Rescue Service which sets out concisely what they should do in the event of a fire.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Communicate and verify understanding of the Stay Put Policy during tenancy visits using trained Housing Officers, scripted questions, declarations and documented checklists.
Verbatim wording from the response “The Stay Put Policy is verbally communicated to tenants of the Stay Put Blocks when an annual Tenancy Audit Visit is carried out by Housing Officers. Housing Officers are trained on Fire Safety Awareness and how to communicate the Stay Put Policy. This training is refreshed annually.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Post Fire Safety Notices through all leaseholder properties’ letterboxes and explain leaseholders’ responsibility to inform and educate sub-tenants.
Verbatim wording from the response “Fire Safety Notices will be posted through the letterbox of all leaseholder properties and leaseholders will be made aware that it is their responsibility as landlord to make sure that their sub-tenants are aware of the Stay Put Policy and understand it. This will start with immediate effect.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Require Housing Officers conducting Tenancy Audit Visits to complete enhanced training on communicating with tenants whose first language is not English.
Verbatim wording from the response “Housing Officers undertaking Tenancy Audit Visits will be required to undertake enhanced training on communicating with tenants who don’t speak English as a first language.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Use proactive telephone calls to discuss fire safety, check tenants’ understanding and update relevant records.
Verbatim wording from the response “In addition to the above, Proactive Calls to tenants have been introduced whereby the Council will attempt to contact all tenants by telephone and discuss fire safety and to check understanding about the Stay Put Policy where appropriate amongst other matters. This method of communication is also used to update our records of any changes in the tenant’s details, and listen to tenant’s views on how safe and secure they feel.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Explore the effectiveness of displaying additional communal notices explaining that Fire Safety Notices can be requested in other languages.
Verbatim wording from the response “The Council is also exploring the effectiveness of also displaying an additional notice in communal areas of all Stay Put Blocks explaining that the Fire Safety Notice can be requested in other languages.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Consider increasing targeted digital communications conveying the Stay Put Policy to residents in Stay Put Blocks.
Verbatim wording from the response “The Council will consider increasing the use of targeted digital communication methods to convey the message of Stay Put to residents in Stay Put Blocks e.g. including this information in mast banners, signage boxes, tenants e bulletins and rent bills.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_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 Provide accessible fire-safety communication through translation, imagery, disability-adapted communication, interpreters and coordinated support for tenants requiring additional assistance.
Verbatim wording from the response “Where English is not a tenant’s first language, the Lettings staff will employ the services of a translator to attend Sign Up Visits with them to translate the Stay Put Policy (amongst other things) and to interpret any questions asked. This service is free of charge to tenants. This process is recorded in a recently developed Fire Safety Advice Check List. If a tenant requires ongoing translation support at Tenancy Audit Visits this is provided by arranging for the attendance of the family and friends who speak English or if necessary the services of a professional translator will again be provided by the Council.” Source location 2021-0205-Response-from-Stoke-on-Trent-City-Council_Published
Open published response
Concerns raised 3 Lack of safe medication storage for residents requiring supervision View source Use of untrained staff to conduct incident investigations View source Perfunctory incident investigations 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.
×
AI-generated summary
Geoffrey Peter Banks · 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
Geoffrey Peter Banks, aged 64, took 44 co-codamol tablets after pulling open a locked medicine cupboard at his assisted accommodation on 1 January 2020. He was admitted to hospital and died on 8 January 2020 from an acute heart attack; the overdose contributed to his death, although it was not possible to determine whether it was accidental or deliberate. Concerns were raised about the lack of safe medication storage for residents needing supervision and about the apparent investigation being perfunctory and conducted by an untrained staff member.
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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Lack of safe medication storage for residents requiring supervision
Wider context from the report “(1) The deceased resided at Oak Priory and was the tenant of a privately rented flat in a scheme from a housing provider. He was on a care package provided by Comfort Call under a contract from Stoke on Trent Council. He received visit four times per day principally to administer medication. The medicine was kept in a locked kitchen cupboard in his flat. He had been identified as not being able to manage his own medication. The tenant was easily able to pull open the cupboard door and the barrel of the lock fell out. He overdosed on medication. There appears to be no system of safe storage in place where a resident has been identified as being in need of supervision with medication.
(2)The apparent investigation into the incident was perfunctory and carried out by an untrained member of staff.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Use of untrained staff to conduct incident investigations
Wider context from the report “(1) The deceased resided at Oak Priory and was the tenant of a privately rented flat in a scheme from a housing provider. He was on a care package provided by Comfort Call under a contract from Stoke on Trent Council. He received visit four times per day principally to administer medication. The medicine was kept in a locked kitchen cupboard in his flat. He had been identified as not being able to manage his own medication. The tenant was easily able to pull open the cupboard door and the barrel of the lock fell out. He overdosed on medication. There appears to be no system of safe storage in place where a resident has been identified as being in need of supervision with medication.
(2)The apparent investigation into the incident was perfunctory and carried out by an untrained member of staff .
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Perfunctory incident investigations
Wider context from the report “(1) The deceased resided at Oak Priory and was the tenant of a privately rented flat in a scheme from a housing provider. He was on a care package provided by Comfort Call under a contract from Stoke on Trent Council. He received visit four times per day principally to administer medication. The medicine was kept in a locked kitchen cupboard in his flat. He had been identified as not being able to manage his own medication. The tenant was easily able to pull open the cupboard door and the barrel of the lock fell out. He overdosed on medication. There appears to be no system of safe storage in place where a resident has been identified as being in need of supervision with medication.
(2)The apparent investigation into the incident was perfunctory and carried out by an untrained member of staff.
” Open source report
Concerns raised 16 Inadequate recording of food and fluid intake View source Failure to obtain full details before closing Adult Protection investigations View source Failure to refer for dietetic assessment after considerable weight loss View source Failure to verify correct pressure mattress function View source Inadequate staff training in pressure mattress management View source Delays in referral to Tissue Viability Nurses View source Inadequate staff training in record keeping View source Failure to maintain continence-related cleanliness before specialist assessment View source Poor continuity of care staff View source Failure to record identified pressure mattress faults View source Failure to identify staff completing care records View source Failure to record declined interventions View source Unavailability of nursing staff for Tissue Viability Nurse calls View source Failure of staff to appreciate the importance of prescribed nutritional supplements View source Failure to carry out pressure sore repositioning plans View source Falsification of pressure sore repositioning records View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Janine Eugenie Pierrette KAISER · 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
Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing care.
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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of food and fluid intake
Wider context from the report “2. Records were difficult to interpret and did not accurately record times at which fluid and food had been offered to the deceased. The amounts taken by the deceased were not adequately recorded.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain full details before closing Adult Protection investigations
Wider context from the report “9. Single agency staff investigating Adult Protections Referrals had closed their investigation and recorded the allegations as unsubstantiated without obtaining full details of concerns raised by other professionals.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to refer for dietetic assessment after considerable weight loss
Wider context from the report “7. The deceased had lost a considerable amount of weight but there was no referral to a dietician (although the GP had been consulted regarding her weight loss and had prescribed supplements) The importance of the supplements was not fully appreciated by all of the staff. The deceased’s weight was maintained during a hospital stay but deteriorated on her return to New Park Nursing 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to verify correct pressure mattress function
Wider context from the report “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off . The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in pressure mattress management
Wider context from the report “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to Tissue Viability Nurses
Wider context from the report “6. Referral to Tissue Viability nurses should have been done sooner.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in record keeping
Wider context from the report “3. Staff appeared inadequately trained in record keeping.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continence-related cleanliness before specialist assessment
Wider context from the report “8. The deceased was incontinent and had required cleaning before Tissue Viability Nurses were able to examine her.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Poor continuity of care staff
Wider context from the report “4. There was poor continuity of staff.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record identified pressure mattress faults
Wider context from the report “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to identify staff completing care records
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record declined interventions
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Unavailability of nursing staff for Tissue Viability Nurse calls
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to appreciate the importance of prescribed nutritional supplements
Wider context from the report “7. The deceased had lost a considerable amount of weight but there was no referral to a dietician (although the GP had been consulted regarding her weight loss and had prescribed supplements) The importance of the supplements was not fully appreciated by all of the staff. The deceased’s weight was maintained during a hospital stay but deteriorated on her return to New Park Nursing 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out pressure sore repositioning plans
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 Stoke-on-Trent City Council; that does not assign responsibility.
PFD Monitor interpretation Falsification of pressure sore repositioning records
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 Share investigation learning with New Park House and recommend improvements to recording practices.
Verbatim wording from the response “Some turns had been missed but Mrs Kaiser was known to regularly refuse to comply with the turn regime in place. It was acknowledged that such refusals were not always documented and the home took this away as a recommendation from the investigation for further work with the staff.” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The investigation was multi-agency, with social work and safeguarding nursing involvement, rather than a single-agency investigation.
Verbatim wording from the response “9. Single agency staff investigating Adult Protection Referrals had closed their investigation and recorded the allegations as unsubstantiated without obtaining full details of concerns raised by other professionals.” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Issues arising after the hospital return were not notified to the City Council, so they were not investigated by it.
Verbatim wording from the response “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The investigation found that advice and support had been sought from Tissue Viability Nurses through three referrals and assessments in June and July 2014.
Verbatim wording from the response “6. The referral to Tissue Viability Nurses should have been made sooner.” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The investigation found no evidence that fluid and food records were difficult to interpret or inaccurately recorded.
Verbatim wording from the response “2. Records were difficult to interpret and did not accurately record times at which fluid and food had been offered to the deceased. The amounts taken by the deceased were not adequately recorded” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The investigation found no evidence that the pressure-sore management plan was inadequately followed or that records had been falsified.
Verbatim wording from the response “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.” Source location 2015-0272-Response-by-Stoke-on-Trent-Council_Redacted
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations