Wolverhampton City Council

Local government · English metropolitan district council

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First report 22 Feb 2017•Latest report 25 Aug 2022

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

Naming this recipient

Published responses
50%

Found for named reports

Concerns addressed
5

Across all linked responses

Stated actions
11

Described in responses

Concerns and recipient responses

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

  1. Black Country

    AI-generated summary

    Charles Evans · 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

    Charles Evans, a resident at Hibiscus House, choked on food in the communal dining room on 29 May 2022, suffered cardiac arrest and severe hypoxic brain injury, and died in hospital the following day. The concerns included inadequate CPR and first-aid provision, absence of a defibrillator and emergency communication arrangements, insufficient staffing and emergency procedures in the dining room, and weaknesses in risk assessment and reporting processes.

    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of an emergency response procedure

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff training in CPR

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish and implement a service-provider action plan for improving quality and safety

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a proper procedure for staff to report concerns about residents

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of reliable emergency communication facilities in the residents’ dining room

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure staff know who else is on duty

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct further risk assessments after a resident’s return from hospital

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of a defibrillator on site

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of a registered first aider on the premises

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of staff presence in the communal dining room during mealtimes

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to monitor progress towards the quality and safety action plan

    Wider context from the report

    “During the course of the inquest I heard evidence from Faye Cadogan Registered Manager Hibiscus House and Norma Chambers Catering Assistant at Hibiscus House. 1. None of the Carers employed at Hibiscus House had any training in CPR. The carer on duty was qualified to Level 2 Diploma in Health & Social care which does not include any training in first aid; 2. At the time of the incident there were no staff members trained in CPR (Coroner was told this had been rectified post Mr Evans death); 3. There was no Registered First Aider at the premises; 4. There was no defibrillator on site; 5. There was no requirement for any staff to be on duty in the communal dining room during mealtimes despite the fact the Hibiscus House could cater for residents with special dietary requirements; 6. There was no emergency bell/alarm or telephone in the residents’ dining room. Staff were expected to use their mobile phone to call for help; 7. There was no procedure for what should happen in an emergency situation (in this instance the catering staff member who found Mr Evans located a carer instead of calling 999 themselves; 8. Staff did not know who else was on duty at any given time; 9. There was no proper procedure in place for staff to report concerns about residents; 10. No further risk assessments were being conducted if a resident returned to Hibiscus House after a hospital admission to ensure the facility could still meet the needs of the resident (Coroner was told staff relied on a discharge summary and/or the GP); 11. Post inquest, the Coroner noted the CQC Inspection report for Hibiscus House Domiciliary Care Agency dated July 2019 which rated the facility as ‘requiring improvement’. The Coroner is concerned to establish whether the service provider put forward an action plan following the CQC Inspection setting out what they would do to improve the standards of quality and safety and whether the CQC monitored any progress towards said plan. ”
    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

    Review staff training, including mandatory training and emergency-response skills and competences.

    Verbatim wording from the response

    “The plan includes a review of staff training to ensure all staff have completed mandatory and/or relevant training. This includes assurances that staff have the right skills and competences to react appropriately in an emergency situation.”

    Source location

    Response from Wolverhampton City Council
    Page 1 · response
    Published 4 November 2022

    Open published response

    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

    Implement and monitor an improvement plan addressing care quality and service safety concerns.

    Verbatim wording from the response

    “An unannounced monitoring visit to the service was undertaken by the Quality Assurance Team. The Council was not assured that the service was operating safely, therefore a recommendation to suspend the service from any new business was proposed and agreed. An improvement plan has been implemented and agreed with the provider. A meeting will be held in due course to review this plan.”

    Source location

    Response from Wolverhampton City Council
    Page 1 · response
    Published 4 November 2022

    Open published response

  2. Black Country

    AI-generated summary

    Edna May Davenport · 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

    Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of home manager follow-up checks after deterioration

    Wider context from the report

    “(7) No further checks were carried out by the home manager after this time and it appeared that evidence of the deceased becoming unwell and suffering with episodes of drowsiness were not recorded or indeed reported by staff caring for her. I am concerned that Oak Court does not have a clear policy in place to manage head injuries; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document increased observation arrangements in written records or care plans

    Wider context from the report

    “(1) During the course of the inquest, I heard evidence that buzzer/alarm in the deceased room had been removed/disabled due to a previous incident where the deceased had attempted to place the cord around her neck. The family were told that as a result, observations of the deceased had been increased to every 15 minutes day and night. There was no evidence of this in any written records or care plan and no evidence of alternative arrangements in her care plan being made to enable the deceased to call for assistance from her room should it be needed given her disabilities; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record or report resident deterioration and drowsiness

    Wider context from the report

    “(7) No further checks were carried out by the home manager after this time and it appeared that evidence of the deceased becoming unwell and suffering with episodes of drowsiness were not recorded or indeed reported by staff caring for her. I am concerned that Oak Court does not have a clear policy in place to manage head injuries; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record resident bedroom-door status

    Wider context from the report

    “(3) I also heard in evidence that the deceased preferred to have her bedroom door left open but this did not form part of her care plan and there was no evidence as to when the door was in fact left open, or when it was closed, or indeed whether the door was open when the other resident was found in the deceased’s room; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake violence risk assessments after admission or incidents

    Wider context from the report

    “(4) I heard evidence during the inquest that the other resident suspected to have been the assailant was a new referral to the home and that there was a lack of information on her admission. The evidence at inquest was that staff were unaware that she was aggressive as a result of her vascular dementia. There was some evidence identified during the police investigation that this resident had attacked a member of staff shortly after her admission and that she had been inappropriately placed at Oak Court house. There was no evidence that any risk assessment had been undertaken after that resident’s admission or after the first alleged attack to address the risk of violence that the resident posed to others by virtue of the extent of her dementia; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of alternative arrangements enabling residents with disabilities to call for assistance from their rooms

    Wider context from the report

    “(1) During the course of the inquest, I heard evidence that buzzer/alarm in the deceased room had been removed/disabled due to a previous incident where the deceased had attempted to place the cord around her neck. The family were told that as a result, observations of the deceased had been increased to every 15 minutes day and night. There was no evidence of this in any written records or care plan and no evidence of alternative arrangements in her care plan being made to enable the deceased to call for assistance from her room should it be needed given her disabilities; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record instructions for ongoing checks and escalation

    Wider context from the report

    “(6) The evidence was that staff had been informed by the Manager to continue carrying out hourly checks and to call an ambulance if there was any change but there was no evidence of this in any of the deceased’s records or daily notes; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record the timing and findings of resident observations

    Wider context from the report

    “(2) I heard evidence that the deceased was subject to hourly observations but that these observations were not recorded as to when they actually took place or what was observed. Therefore, it was not possible to ascertain how long the other resident had been in the room with the deceased or how long the assault went on for; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of information on admission of new residents

    Wider context from the report

    “(4) I heard evidence during the inquest that the other resident suspected to have been the assailant was a new referral to the home and that there was a lack of information on her admission. The evidence at inquest was that staff were unaware that she was aggressive as a result of her vascular dementia. There was some evidence identified during the police investigation that this resident had attacked a member of staff shortly after her admission and that she had been inappropriately placed at Oak Court house. There was no evidence that any risk assessment had been undertaken after that resident’s admission or after the first alleged attack to address the risk of violence that the resident posed to others by virtue of the extent of her dementia; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a clear head-injury management policy

    Wider context from the report

    “(7) No further checks were carried out by the home manager after this time and it appeared that evidence of the deceased becoming unwell and suffering with episodes of drowsiness were not recorded or indeed reported by staff caring for her. I am concerned that Oak Court does not have a clear policy in place to manage head injuries; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to include resident bedroom-door preferences in care plans

    Wider context from the report

    “(3) I also heard in evidence that the deceased preferred to have her bedroom door left open but this did not form part of her care plan and there was no evidence as to when the door was in fact left open, or when it was closed, or indeed whether the door was open when the other resident was found in the deceased’s room; ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in seeking medical review after head injury

    Wider context from the report

    “(8) The deceased was an elderly lady who had suffered a head injury and was known to be anti-coagulant medication, yet no medical review was sought until an ambulance was called on 29/11/19 when the deceased became unresponsive. A concern was raised by hospital staff on her admission and a safe guarding referral was made. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide and adjust neurological observations after head injury

    Wider context from the report

    “(5) I heard evidence that there were obvious signs of an injury to Edna’s head in the form of the injury to her eye which resulted in bruising and swelling. There was also evidence that the deceased had been punched to the head. The District Nurse recorded that Edna had had a headache and the deceased had complained to her daughter about suffering with a headache shortly after the assault. Despite this, no neuro observations were undertaken and there was no change to the frequency of Edna’s observations; ”
    Open source report

  3. Black Country

    AI-generated summary

    Mrs Elsa Reid · 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

    Mrs Elsa Reid, a 92-year-old woman, was admitted to hospital after a fall that caused a complex fractured hip and was later discharged to a care home for rehabilitation. She died on 20 December 2018 after developing a pulmonary embolism. The principal concerns were inadequate communication about her mobility and hoisting needs, delays in resolving conflicting instructions, and an insufficient mobility regime that may have increased the risk of complications including pulmonary embolism.

    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate communication between the hospital and occupational therapist

    Wider context from the report

    “1. Evidence emerged during the inquest that there was inadequate communication between the Hospital and occupational therapist to resolve the issue in a timely manner which resulted in a minimal exercise/mobility regime being implemented. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient urgency in resolving the matter

    Wider context from the report

    “2. Although it is recognised some bed bound exercises were completed there was insufficient urgency amongst those professionals involved to resolve the matter as quickly as possible and thereby reduce the risks of complications, including pulmonary embolism from developing. ”
    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Minimal exercise and mobility regime

    Wider context from the report

    “1. Evidence emerged during the inquest that there was inadequate communication between the Hospital and occupational therapist to resolve the issue in a timely manner which resulted in a minimal exercise/mobility regime being implemented. ”
    Open source report

  4. Black Country

    AI-generated summary

    Mr Christopher Brookes · 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

    Mr Christopher Brookes, aged 22, fell around 40 feet from a gate at Wolverhampton bus station after leaving through a fire exit and died from his injuries on 29 October 2017. The inquest heard that there had been a similar previous incident at the same location and that security guards failed to attend when an alarm indicated unauthorised use of the fire exit.

    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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Risk of falling to the road below at the location

    Wider context from the report

    “1. Evidence emerged during the inquest that there was a previous incident at the same location involving a member of public who narrowly escaped falling to the road below in April 2017 in similar 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 Wolverhampton City Council; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of security guards to attend alarms indicating unauthorised use of the fire exit

    Wider context from the report

    “2. Evidence also emerged during the inquest that an alarm would be activated if the fire exit was used. It appears that security guards employed to deal with unauthorised use of the fire exit failed to attend. ”
    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

    Install additional safety lighting and warning signage along the fire-escape route.

    Verbatim wording from the response

    “In addition to the above, the Council has installed additional safety lighting on the fire escape route, together with signage, highlighting the existence of a drop below the fire escape route. The Council has also committed to working with the other relevant parties, including the combined authority and the other users of the building, to include Sainsburys supermarket, who occupy and are of the ground floor of the building.”

    Source location

    2018-0055-Response-by-City-of-Wolverhampton
    Page 2 · response
    Published 8 June 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Responsibility for operating the bus station, including its fire escape door and security services, rests with the combined transport executive.

    Verbatim wording from the response

    “2. With regard to the alarm being activated, as you may be aware from the evidence given at the Inquest itself, the fire escape door from the bus station is not something under the control or operation of City of Wolverhampton Council. The combined transport executive has responsibility for and control over the bus station operation, including the fire escape door from the bus station itself. In addition, the security services contracted to deal with that element of the operations is something entirely under the control and responsibility of the combined transport executive. The Council has no control over the provision of security for the relevant area.”

    Source location

    2018-0055-Response-by-City-of-Wolverhampton
    Page 1 · response
    Published 8 June 2018

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    The Council lacks control over the bus station fire escape door and the security arrangements for the relevant area.

    Verbatim wording from the response

    “2. With regard to the alarm being activated, as you may be aware from the evidence given at the Inquest itself, the fire escape door from the bus station is not something under the control or operation of City of Wolverhampton Council. The combined transport executive has responsibility for and control over the bus station operation, including the fire escape door from the bus station itself. In addition, the security services contracted to deal with that element of the operations is something entirely under the control and responsibility of the combined transport executive. The Council has no control over the provision of security for the relevant area.”

    Source location

    2018-0055-Response-by-City-of-Wolverhampton
    Page 1 · response
    Published 8 June 2018

    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