Summary
Trends
Evidence
Reports, concerns and published responses Receiving a report does not make the recipient responsible for every concern in it. PFD Monitor does not verify whether stated actions happened.
Reports over time Reports naming this recipient by issue year.
* 2026 is projected from reports observed to 7 Sep 2026.
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
Concerns raised 3 Failure to discuss and agree care plans and needs assessments with service users’ families View source Inconsistent application of controls preventing service commencement without a care plan and needs assessment View source Care plans and needs assessments failing to incorporate complete available information View source
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
Stanley Langdon · 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
Stanley Langdon died at Dipton Manor Care Home on 21 May 2017 from complications arising from a periprosthetic left femoral fracture sustained while carers assisted him to climb onto a minibus. The report states that he would not have sustained the fracture if he had been transferred in a wheelchair using the available hydraulic lift. The principal concerns were that services began without an adequate care plan or needs assessment, and that care planning was not based on complete information or agreed with his family, creating a risk of similar accidents and deaths in future.
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 The Haven Day Centre (Burnhope); that does not assign responsibility.
PFD Monitor interpretation Failure to discuss and agree care plans and needs assessments with service users’ families
Wider context from the report “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user.
(5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently, and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users.
(6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day)
(7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council, and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day).
” 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 The Haven Day Centre (Burnhope); that does not assign responsibility.
PFD Monitor interpretation Inconsistent application of controls preventing service commencement without a care plan and needs assessment
Wider context from the report “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user.
(5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently , and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users .
(6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available, and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day)
(7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council , and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day).
” 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 The Haven Day Centre (Burnhope); that does not assign responsibility.
PFD Monitor interpretation Care plans and needs assessments failing to incorporate complete available information
Wider context from the report “(4) The inquest was told in evidence that Durham County Council had systems in place to ensure that service providers such as the Haven Day Care Centre would not be authorised to provide services unless and until they had received a care plan and assessment of needs in relation to any specific service user.
(5) The inquest was also told in evidence that the systems referred to in (4) were not being applied consistently, and service providers (specifically Haven Day Care Centre) were still commencing the provision of services to service users without receiving care plans and assessments of need for particular service users.
(6) The care plan that was put in place for the deceased at the Haven Day Care Centre after services had begun to be provided to him was not based on all the information that was or should have been available , and that the said care plan had not been discussed and agreed with the deceased’s family (it being noted that the deceased was a dementia sufferer heavily reliant on his family for care from day to day)
(7) It appears to me that there is a risk that similar situations as that applying to the deceased may arise in the future, whereby the Haven Day Care Centre may begin to provide services to a service user without having been provided with relevant information in the form of a care plan and needs assessment from Durham County Council, and without having in place their own care plan and needs assessment based on complete information and adequate discussion with a service user’s family (in circumstances where the service user was heavily reliant on the family for care from day to day).
” 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
Data last updated 7 September 2026