25 Aug 2022 Charles Evans · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 11 Lack of an emergency response procedure View source Lack of staff training in CPR View source Failure to establish and implement a service-provider action plan for improving quality and safety View source Lack of a proper procedure for staff to report concerns about residents View source Lack of reliable emergency communication facilities in the residents’ dining room View source Failure to ensure staff know who else is on duty View source Failure to conduct further risk assessments after a resident’s return from hospital View source Unavailability of a defibrillator on site View source Unavailability of a registered first aider on the premises View source Lack of staff presence in the communal dining room during mealtimes View source Failure to monitor progress towards the quality and safety action plan View source See 8 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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
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
Open published response
3 Apr 2020 Edna May Davenport · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 13 Failure of home manager follow-up checks after deterioration View source Failure to document increased observation arrangements in written records or care plans View source Failure to record or report resident deterioration and drowsiness View source Failure to record resident bedroom-door status View source Failure to undertake violence risk assessments after admission or incidents View source Lack of alternative arrangements enabling residents with disabilities to call for assistance from their rooms View source Failure to record instructions for ongoing checks and escalation View source Failure to record the timing and findings of resident observations View source Lack of information on admission of new residents View source Lack of a clear head-injury management policy View source Failure to include resident bedroom-door preferences in care plans View source Delays in seeking medical review after head injury View source Failure to provide and adjust neurological observations after head injury View source See 10 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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
2 Apr 2019 Mrs Elsa Reid · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 3 Inadequate communication between the hospital and occupational therapist View source Insufficient urgency in resolving the matter View source Minimal exercise and mobility regime View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
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
22 Feb 2017 Mr Christopher Brookes · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 2 Risk of falling to the road below at the location View source Failure of security guards to attend alarms indicating unauthorised use of the fire exit View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
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
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
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
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations