The Salvation Army

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First report 4 Jul 2014•Latest report 4 Jul 2014

Reports, concerns and published responses

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
100%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
3

Described in responses

Concerns and recipient responses

Statements from The Salvation Army linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. West Sussex

    AI-generated summary

    Stanley Bere · 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 Bere, a resident of a nursing home, fell on 31 October 2011 and sustained a fractured ankle that was not identified until 8 November 2011. He later developed an infection and died on 4 June 2012; the inquest recorded congestive cardiac failure and bronchopneumonia, with the fractured ankle and subsequent infection contributing to his death. Concerns included incomplete Cardex records, inadequate follow-up of incident reports, and insufficient cross-referencing or monitoring of records, which meant his injuries were not identified promptly.

    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 Salvation Army; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of cross-referencing or monitoring of Cardex and incident reports

    Wider context from the report

    “(3) The lack of cross referencing or monitoring of these Cardex system and the Incident reports appears to have been the reason why Mr Bere’s injuries were not picked up soon by 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 The Salvation Army; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to follow up or update incident reports when further information becomes available

    Wider context from the report

    “(2) Incident reports were being completed but in Mr Bere’s case his incident report was not followed up or updated even when further information was available as to the extent of Mr Bere’s injury. ”
    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 Salvation Army; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to properly complete Cardex records

    Wider context from the report

    “(1) There was evidence provided at the Inquest that showed that the Cardex system used at the home was not being properly completed. Dates, on occasions, appeared to be out of order and important information such where a patient had fallen was not being recorded. Family concerns also did not appear to always be recorded. ”
    Open source report

    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

    Strengthen incident reporting by recording and updating falls, accidents and near misses, with regular management auditing and follow-up.

    Verbatim wording from the response

    “We have tightened up our reporting systems, particularly ensuring all falls, accidents and "near misses" are recorded, and updating on any accident or incident. A more secure system of archiving has been introduced. We have also found a copy of a receipt we asked the coroner's officer to sign when taking the records, as she had no letter with her. I have enclosed a copy for your records. The home manager regularly checks that issues are recorded and followed up in his regular auditing of documents. Staff are aware of the consequences if they do not follow correct procedures. These improvements were put in place immediately following the inquest.”

    Source location

    2014-0339-Response-by-Older-Peoples-Services
    Page 1 · response
    Published 4 July 2014

    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

Data last updated 7 September 2026