Weightmans LLP

Private and voluntary organisations · Limited liability partnership

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First report 10 Jul 2015•Latest report 9 Feb 2023

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: 4
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

9 Feb2023
Worcestershire
Concerns raised3
1. Lack of staff understanding of duties and responsibilities to update residents’ documentation
2. Failure to consider measures to mitigate residents’ increased falls risk
3. Failure to update residents’ falls risk assessment and care plan documentation following falls
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Bridget GORMLEY · 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

Bridget Gormley fell at her care home in Worcester on 20 July 2022 and was found to have significant traumatic intracranial bleeding. She was transferred to Worcestershire Royal Hospital, where she died on 31 July 2022. The principal concerns were that her falls risk assessment and care plan were not updated after repeated falls, and that staff may not have understood their duties to update residents’ documentation.

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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff understanding of duties and responsibilities to update residents’ documentation
Wider context from the report
“(1) During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court’s registered home manager, ████████, conceded in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care plan document were updated following any of these falls, and that they should have been so updated. This meant that: (a) Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that she presented an increased risk of suffering a fall; and (b) Measures to mitigate that increased risk were not considered. Such measures could have included: (i) Asking a GP to refer Mrs. Gormley to the falls clinic; (ii) Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising; (iii) Referring her to Occupational Therapy for mobility aids such as a walking stick or frame; (iv) Briefing staff at Latimer Court to intervene whenever Mrs. Gormley was seen mobilising by herself, and to offer her assistance. (2) ████████ was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents’ documentation in such 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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Failure to consider measures to mitigate residents’ increased falls risk
Wider context from the report
“(1) During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court’s registered home manager, ████████, conceded in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care plan document were updated following any of these falls, and that they should have been so updated. This meant that: (a) Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that she presented an increased risk of suffering a fall; and (b) Measures to mitigate that increased risk were not considered. Such measures could have included: (i) Asking a GP to refer Mrs. Gormley to the falls clinic; (ii) Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising; (iii) Referring her to Occupational Therapy for mobility aids such as a walking stick or frame; (iv) Briefing staff at Latimer Court to intervene whenever Mrs. Gormley was seen mobilising by herself, and to offer her assistance. (2) ████████ was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents’ documentation in such 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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Failure to update residents’ falls risk assessment and care plan documentation following falls
Wider context from the report
“(1) During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court’s registered home manager, ████████, conceded in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care plan document were updated following any of these falls, and that they should have been so updated. This meant that: (a) Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that she presented an increased risk of suffering a fall; and (b) Measures to mitigate that increased risk were not considered. Such measures could have included: (i) Asking a GP to refer Mrs. Gormley to the falls clinic; (ii) Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising; (iii) Referring her to Occupational Therapy for mobility aids such as a walking stick or frame; (iv) Briefing staff at Latimer Court to intervene whenever Mrs. Gormley was seen mobilising by herself, and to offer her assistance. (2) ████████ was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents’ documentation in such circumstances. ”
Open source report
3 Jan2023
Sefton, St Helens and Knowsley
Concerns raised1
1. Failure to supervise syringe medication
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Beryl ELLISON · 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

Beryl Ellison was receiving end-of-life care at Alexandra Care Home and was found deceased there on 28 June 2022. The inquest concluded that her death resulted from underlying poor health in combination with taking an excessive quantity of prescribed medication. Concerns included unsupervised access to syringe medication, prior family reports about medication being left in her room, and the absence of an explanation for the excessive oxycodone concentration found after her death.

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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Failure to supervise syringe medication
Wider context from the report
“Mrs Ellison was resident at Alexandra Care Home and was found deceased on 28th June 2022 by staff. Her family expressed concern that she had been left with syringe medication unsupervised by staff and raised concerns about this with the care home both historically and four days prior to her death. A post mortem examination revealed Mrs Ellison to have an excessive concentration of oxycodone in her system which was likely to exceed any acquired tolerance level. The evidence heard at inquest revealed no explanation as to why Mrs Ellison was found to have taken the excessive quantity of oxycodone which contributed to her death. Furthermore, the systems at the care home were stated categorically to be the same as those that were in place prior to Mrs Ellison's death. ”
Open source report
2 Nov2015
Essex
Concerns raised5
1. Lack of up-to-date knowledge among general practitioners about epiglottitis in adults
2. Lack of effective training of ambulance staff on when to convey a patient to hospital
3. Failure to learn from prior events
1. Lack of effective training of ambulance staff in use of the sepsis screening tool
2. Ineffective use of the sepsis screening tool by ambulance staff
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Steven David Jackson · 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

Steven David Jackson attended Southend Hospital on 5 March 2014, was later taken there by ambulance after collapsing, and died at 14:26. The inquest recorded acute epiglottitis as the cause of death and identified very serious failings in the care provided by ambulance staff. Concerns also included an out-of-hours general practitioner’s apparently outdated knowledge of epiglottitis in adults.

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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Lack of up-to-date knowledge among general practitioners about epiglottitis in adults
Wider context from the report
“1. The general practitioner, employed by the out of hours service IC24, seemed to have out of date knowledge of the incidence of epiglottitis generally. He seemed to be under the impression that it was still very much a condition found among children and would not be expected in an adult such as Mr Jackson. ”
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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective training of ambulance staff on when to convey a patient to hospital
Wider context from the report
“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”
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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Failure to learn from prior events
Wider context from the report
“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”
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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Lack of effective training of ambulance staff in use of the sepsis screening tool
Wider context from the report
“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”
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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Ineffective use of the sepsis screening tool by ambulance staff
Wider context from the report
“1. The paramedic who attended at around 10:00am gave evidence which indicated that she did not seem to have learned from the events in March 2014. 2. She had not used the sepsis screening tool effectively in March 2014 and the court is not confident that she would, in similar circumstances again, use it effectively. 3. There needs to be effective training of ambulance staff in the use of the tool and in the circumstances as to when it is appropriate to convey a patient to hospital. ”
Open source report
10 Jul2015
Manchester North
Concerns raised3
1. Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma
2. Failure to notify the hospital trust of ambulance presence within hospital grounds
3. Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Colin Moulton · 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

Colin Moulton was discovered deceased on 14 February 2013 near the perimeter wall of the Irwell Unit at Fairfield General Hospital, after leaving the Accident and Emergency Department the previous day. Concerns included ineffective communication during handover, incorrect triage, failure to recognise confusion, and the absence of a formal capacity assessment or other documented measures when he attempted to leave. The inquest narrative stated that his death was contributed to by neglect.

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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma
Wider context from the report
“1. When Mr Moulton was admitted to A & E on the 13th February 2013, critical information was conveyed by means of an audible handover from the paramedic to the receiving triage nurse. Following this incident, the Pennine Acute Trust now requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional requirement that those actions be documented. It would be helpful if an additional copy of the paramedic pro-forma could be given to and remain with the receiving triage nurse. ”
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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Failure to notify the hospital trust of ambulance presence within hospital grounds
Wider context from the report
“2. At approximately 5pm on the 13th February 2013, a number of administrative staff, whilst en-route home saw Colin Moulton within the hospital grounds near to the Irwell Unit. They perceived him to be ‘ in difficulty’. One of the staff members called for the assistance of an ambulance which duly attended and a paramedics on board apparently were unable to locate Mr Moulton. Had the Ambulance Trust notified the Hospital Trust of their presence within the hospital grounds, this may have tied in with earlier concerns in relation to Mr Moulton of which the Hospital Trust was aware. The Ambulance Trust is requested to consider whether in the future, third parties such as Hospital Trusts might be notified in such 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 Weightmans LLP; that does not assign responsibility.
PFD Monitor interpretation
Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma
Wider context from the report
“1. When Mr Moulton was admitted to A & E on the 13th February 2013, critical information was conveyed by means of an audible handover from the paramedic to the receiving triage nurse. Following this incident, the Pennine Acute Trust now requires the receiving triage nurse to have access to and have sight of the paramedic pro-forma with the additional requirement that those actions be documented. It would be helpful if an additional copy of the paramedic pro-forma could be given to and remain with the receiving triage nurse. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised3

Lack of staff understanding of duties and responsibilities to update residents’ documentation

Failure to consider measures to mitigate residents’ increased falls risk

Failure to update residents’ falls risk assessment and care plan documentation following falls

Concerns raised1

Failure to supervise syringe medication

Concerns raised5

Lack of up-to-date knowledge among general practitioners about epiglottitis in adults

Lack of effective training of ambulance staff on when to convey a patient to hospital

Failure to learn from prior events

Lack of effective training of ambulance staff in use of the sepsis screening tool

Ineffective use of the sepsis screening tool by ambulance staff

Concerns raised3

Failure to provide the receiving triage nurse with access to and sight of the paramedic pro-forma

Failure to notify the hospital trust of ambulance presence within hospital grounds

Failure to document the receiving triage nurse's access to and sight of the paramedic pro-forma