21 Sep 2017 Derek Clifford Dudley · Prevention of Future Deaths report Surrey
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Concerns raised 8 Failure to require trainee Telecare Operators to obtain approval before closing calls View source Failure to persist in offering and persuading service users to accept help after alarm activation View source Failure to inform emergency contacts of the service user’s control over whether they are telephoned View source Failure to take further action when follow-up contact after an unanswered alarm call fails View source Insufficient background information available to Telecare Operators for assessing service user needs View source Lack of pro forma questions for assessing needs after alarm activation View source Allowing trainee Telecare Operators to take calls without direct supervision View source Failure to keep alarm calls open until service users are safely recovered from falls View source See 5 more concerns
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
Derek Clifford Dudley · 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
Derek Clifford Dudley was found deceased from hypothermia outside the back door of his home on 6 March 2017, after previously activating his community alarm following a fall. Concerns included the call being ended before he had got up, limited follow-up after a later unanswered call, unsupervised trainee operators, the absence of pro forma questions, and insufficient background information for assessing service users’ needs.
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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Failure to require trainee Telecare Operators to obtain approval before closing calls
Wider context from the report “The Telecare operator who took Mr Dudley’s call was in her probationary period with the Service but was able to take the call without direct supervision and did not need to seek approval before closing the call .
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Failure to persist in offering and persuading service users to accept help after alarm activation
Wider context from the report “Mr Dudley was only offered an ambulance once during the course of the telephone conversation and no attempt was made to persuade him to accept any help.
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Failure to inform emergency contacts of the service user’s control over whether they are telephoned
Wider context from the report “The court heard evidence that Mr Dudley’s emergency contacts believed they would be telephoned automatically if Mr Dudley activated his alarm, and stated they had signed a form agreeing to be called at any time of day or night. Mr Dudley was not asked if he wanted his emergency contacts to be telephoned and ████████ CSS Telecare Service Manager, stated they would not be contacted unless the service user requested this.
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Failure to take further action when follow-up contact after an unanswered alarm call fails
Wider context from the report “The operator attempted to contact Mr Dudley by telephone again 1.5 hours later , which ████████ again stated was in breach of Telecare’s policy, but there was no answer and no further action was taken.
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Insufficient background information available to Telecare Operators for assessing service user needs
Wider context from the report “████████ also confirmed that whilst an extensive assessment of new service users is undertaken with their next of kin, this information is not accessible to the Telecare Operators who are provided with a very brief sentence describing the service user’s requirements.
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Lack of pro forma questions for assessing needs after alarm activation
Wider context from the report “Evidence was heard during the inquest that no pro forma questions are provided to the Telecare operators for dealing with calls and call handling guidance is provided to each operator on a USB stick which they can access via their work computer if needed.
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Allowing trainee Telecare Operators to take calls without direct supervision
Wider context from the report “The Telecare operator who took Mr Dudley’s call was in her probationary period with the Service but was able to take the call without direct supervision and did not need to seek approval before closing the call.
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Failure to keep alarm calls open until service users are safely recovered from falls
Wider context from the report “The call was terminated without Mr Dudley having got up from his fall , which ████████ confirmed was in breach of the policy of CSS Telecare Service .
” Open source report
9 Mar 2016 Robert Walker · Prevention of Future Deaths report South London
View report summary
Concerns raised 3 Tree trunk near the carriageway edge presenting a danger to road users View source Lack of sufficient deviation markings at the bend View source Path surface capable of causing walkers to slip into the carriageway 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
Robert Walker · 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
Robert Walker, aged 62, died from multiple injuries following a road traffic collision after losing control of his motorcycle on a bend on Old Farleigh Road on 4 August 2015. Concerns included insufficient bend deviation markings, a tree trunk close to the carriageway, and a slippery path leading towards the road.
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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Tree trunk near the carriageway edge presenting a danger to road users
Wider context from the report “(1) The bend lacks sufficient deviation markings
(2) There is a tree trunk near the edge of the carriageway that presents a danger to road users particularly cyclists
(3) A path that approaches the road and is well used by walkers has a surface that could cause walkers to slip into the carriageway.
(The matters of concern are summarised in the report of ████████ from Catford Traffic Police. An extract from his report is attached.
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Lack of sufficient deviation markings at the bend
Wider context from the report “(1) The bend lacks sufficient deviation markings
(2) There is a tree trunk near the edge of the carriageway that presents a danger to road users particularly cyclists
(3) A path that approaches the road and is well used by walkers has a surface that could cause walkers to slip into the carriageway.
(The matters of concern are summarised in the report of ████████ from Catford Traffic Police. An extract from his report is attached.
” 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 Tandridge District Council; that does not assign responsibility.
PFD Monitor interpretation Path surface capable of causing walkers to slip into the carriageway
Wider context from the report “(1) The bend lacks sufficient deviation markings
(2) There is a tree trunk near the edge of the carriageway that presents a danger to road users particularly cyclists
(3) A path that approaches the road and is well used by walkers has a surface that could cause walkers to slip into the carriageway .
(The matters of concern are summarised in the report of ████████ from Catford Traffic Police. An extract from his report is attached.
” 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