Recipient

Westwood Hall Nursing Home

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First report 17 Dec 2025•Latest report 17 Dec 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Westwood Hall Nursing Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Liverpool and the Wirral

    AI-generated summary

    Dorothy Ann MACDONALD · 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

    Dorothy Ann MACDONALD sustained a fractured neck of femur in an unwitnessed fall at her nursing home on 11 August 2025 and died in hospital on 22 August 2025 after being placed on palliative end-of-life care. The report raised concerns that her falls risk and the potential impact of a fall were repeatedly underestimated, and that staff training and referrals to the falls team were not consistently effective or used.

    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 Westwood Hall Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Inaccurate assessment of individual falls likelihood and impact

    Wider context from the report

    “The Deceased was assessed as needing to use a trolley or to have the support of staff to mobilise safely. Despite this, on multiple occasions (and even after the Deceased had fallen at the home, and had aroused concern by attempting to mobilise alone and without a trolley), staff assessed and documented her risk of falling as being at ‘low’ likelihood – a score of 2/5 on the likelihood scale. The Home Manager accepted that this repeated assessment was ‘always wrong’. It was later increased to 3/5, classed as a medium risk. In the court’s opinion this was also wrong. The likely impact of harm was assessed as 3/5 and described as ‘undesirable’. This underestimated the potential impact, as subsequent events proved. The Home Manager was unable to tell the court what rankings of 4 or 5 would represent. The Deceased died as a result of the fractured neck of femur she sustained in a fall at the Care Home. It ought to have been understood by nursing or other senior staff in a nursing home setting that such an injury would be of great seriousness in somebody presenting as the Deceased did, with a fatal outcome following hospital admission after such an injury not being uncommon. The court was told that such risk assessments might be made by any nurse, the Deputy Manager or the Home Manager, and that all had received relevant training. The court is not satisfied that the training was effective and/or was being adopted properly. In this case the assessment of the likelihood of risk was plainly wrong; and the court considers that the assessment of impact was also incorrect. As a result, the overall risk score (likelihood x impact) was understated. In this instance it probably did not make a difference to the control/mitigation measures put in place, but the court is concerned that under-estimation of an individual’s falls risk could place other (current/future) residents at risk of falls which might threaten their lives. The court would like to know what steps are being taken to ensure that all relevant staff have received, understood and consistently act upon suitable and sufficient training in the assessment of falls risk. ”
    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 Westwood Hall Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure effective and consistently adopted falls-risk assessment training

    Wider context from the report

    “The Deceased was assessed as needing to use a trolley or to have the support of staff to mobilise safely. Despite this, on multiple occasions (and even after the Deceased had fallen at the home, and had aroused concern by attempting to mobilise alone and without a trolley), staff assessed and documented her risk of falling as being at ‘low’ likelihood – a score of 2/5 on the likelihood scale. The Home Manager accepted that this repeated assessment was ‘always wrong’. It was later increased to 3/5, classed as a medium risk. In the court’s opinion this was also wrong. The likely impact of harm was assessed as 3/5 and described as ‘undesirable’. This underestimated the potential impact, as subsequent events proved. The Home Manager was unable to tell the court what rankings of 4 or 5 would represent. The Deceased died as a result of the fractured neck of femur she sustained in a fall at the Care Home. It ought to have been understood by nursing or other senior staff in a nursing home setting that such an injury would be of great seriousness in somebody presenting as the Deceased did, with a fatal outcome following hospital admission after such an injury not being uncommon. The court was told that such risk assessments might be made by any nurse, the Deputy Manager or the Home Manager, and that all had received relevant training. The court is not satisfied that the training was effective and/or was being adopted properly. In this case the assessment of the likelihood of risk was plainly wrong; and the court considers that the assessment of impact was also incorrect. As a result, the overall risk score (likelihood x impact) was understated. In this instance it probably did not make a difference to the control/mitigation measures put in place, but the court is concerned that under-estimation of an individual’s falls risk could place other (current/future) residents at risk of falls which might threaten their lives. The court would like to know what steps are being taken to ensure that all relevant staff have received, understood and consistently act upon suitable and sufficient training in the assessment of falls risk. ”
    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 Westwood Hall Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to consistently identify and make appropriate referrals to the falls team

    Wider context from the report

    “In addition, the court was shown that the nursing home’s fall policy indicated that it is good practice to refer cases of falls to the ‘falls team’, but that in practice this was done rarely, partly because the Home Manager lacked confidence in the responsiveness or value of the service. She said that the policy did not specify how many falls should take place prior to a referral. The court would like to know how the nursing home will satisfy itself: (a) that all relevant staff have received, understood and consistently act upon suitable and sufficient education about the circumstances in which, and how, a referral to the falls team should be made; (b) that the service is sufficiently responsive and effective in responding to requests for its specialist input. ”
    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 Westwood Hall Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient responsiveness and effectiveness of falls-team specialist input

    Wider context from the report

    “In addition, the court was shown that the nursing home’s fall policy indicated that it is good practice to refer cases of falls to the ‘falls team’, but that in practice this was done rarely, partly because the Home Manager lacked confidence in the responsiveness or value of the service. She said that the policy did not specify how many falls should take place prior to a referral. The court would like to know how the nursing home will satisfy itself: (a) that all relevant staff have received, understood and consistently act upon suitable and sufficient education about the circumstances in which, and how, a referral to the falls team should be made; (b) that the service is sufficiently responsive and effective in responding to requests for its specialist input. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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