16 Sep 2025 John Franklin · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls View source Failure to establish and communicate whether a careline has been installed View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
John Franklin · 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
John Franklin, who lived alone and was at high risk of falls, suffered a fall after discharge home, followed by dehydration, reduced mobility, contractures and pressure ulcers. He deteriorated despite treatment and died on 16 October 2024; the inquest concluded that death was due to complications of recent falls contributed to by frailty syndrome. The principal concern was that he was discharged home before a careline/lifeline pendant was provided, although the records later indicated that one was installed.
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× 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls
Wider context from the report “Mr Franklin lived alone and was assessed to be at high risk of falls. When he was discharged from Malvern Hospital on the 19 May 2024, he was discharged home before a careline/lifeline pendant was provided .
At the inquest, the evidence of the manager of the Reablement team was that she did not know whether a careline had been installed at the time that Mr Franklin was found on the floor on the morning of the 28 May 2024. She informed the court that a Care Line had been requested for Mr Franklin on the 21 May 2024, and that on the 24 May 2024 during a physiotherapy assessment, Mr Franklin consented to a care line being ordered. The care notes reflected that a care line had been installed on the 22 May 2024.
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to establish and communicate whether a careline has been installed
Wider context from the report “Mr Franklin lived alone and was assessed to be at high risk of falls. When he was discharged from Malvern Hospital on the 19 May 2024, he was discharged home before a careline/lifeline pendant was provided.
At the inquest, the evidence of the manager of the Reablement team was that she did not know whether a careline had been installed at the time that Mr Franklin was found on the floor on the morning of the 28 May 2024. She informed the court that a Care Line had been requested for Mr Franklin on the 21 May 2024, and that on the 24 May 2024 during a physiotherapy assessment, Mr Franklin consented to a care line being ordered. The care notes reflected that a care line had been installed on the 22 May 2024 .
” Open source report
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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 the hospital discharge policy and procedures to ensure assistive technology needs and safe discharge decisions are explicit.
Verbatim wording from the response “To ensure any learning is taken, we have reviewed our policy and procedures for hospital discharge. We are confident that the approach of ensuring AT needs are considered and only safe discharges are agreed is explicit in our process.” Source location 2026-0110 - Response from Worcestershire County Council
Open published response
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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 Consider assistive technology needs and associated risks before every hospital discharge.
Verbatim wording from the response “Prior to hospital discharges we will always consider if there is a need for Assistive Technology (AT) to be in place for a safe discharge. There are occasions where AT is identified as beneficial but not essential and would not be deemed as necessary for safe hospital discharge, for instance where a person has other support means or is safe between calls and has the ability to understand the need to wait between calls and will not mobilise if there is a high risk of falls. Prior to hospital discharge, a triage process is undertaken to identify presenting needs and any risks, which would consider if AT is required to meet essential needs prior to discharge.” Source location 2026-0110 - Response from Worcestershire County Council
Open published response
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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 Share necessary assistive technology requirements with acute colleagues and the person or representative, and arrange provision before discharge.
Verbatim wording from the response “Staff have been reminded of the need to consider any risks when considering the use of AT and identifying if any of those risks must be mitigated through AT being in situ prior to discharge. Where this is deemed necessary for a safe discharge this will be shared with our acute colleagues and the person/representative and will be arranged in advance.” Source location 2026-0110 - Response from Worcestershire County Council
Open published response
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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 Remind staff to identify risks requiring mitigation through assistive technology before discharge.
Verbatim wording from the response “Staff have been reminded of the need to consider any risks when considering the use of AT and identifying if any of those risks must be mitigated through AT being in situ prior to discharge. Where this is deemed necessary for a safe discharge this will be shared with our acute colleagues and the person/representative and will be arranged in advance.” Source location 2026-0110 - Response from Worcestershire County Council
Open published response
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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 Always providing assistive technology before discharge is not feasible because it would significantly delay discharges where it is not essential.
Verbatim wording from the response “We would not be able to commit to AT always being in place prior to discharge as you can appreciate this would delay a significant number of discharges when the need has not been deemed essential.” Source location 2026-0110 - Response from Worcestershire County Council
Open published response
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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 discharge triage process sufficiently identifies when assistive technology is essential for safe discharge, so it need not always be provided beforehand.
Verbatim wording from the response “Prior to hospital discharges we will always consider if there is a need for Assistive Technology (AT) to be in place for a safe discharge. There are occasions where AT is identified as beneficial but not essential and would not be deemed as necessary for safe hospital discharge, for instance where a person has other support means or is safe between calls and has the ability to understand the need to wait between calls and will not mobilise if there is a high risk of falls. Prior to hospital discharge, a triage process is undertaken to identify presenting needs and any risks, which would consider if AT is required to meet essential needs prior to discharge.” Source location 2026-0110 - Response from Worcestershire County Council
Open published response
16 Sep 2025 John Franklin · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 2 Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls View source Failure to confirm and communicate whether a careline had been installed 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
John Franklin · 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
John Franklin, who was frail and at high risk of falls after hip surgery and prolonged hospitalisation, was found on the floor at home after a long lie and subsequently developed pressure ulcers and a deteriorating hip wound. He died on 16 October 2024; the inquest concluded that death was due to complications of recent falls contributed to by frailty syndrome. A substantive concern was that he was discharged home before a careline/lifeline pendant was provided, with uncertainty about whether it had been installed when he was found on the floor.
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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a careline/lifeline pendant before discharge home for a person at high risk of falls
Wider context from the report “Mr Franklin lived alone and was assessed to be at high risk of falls . When he was discharged from Malvern Hospital on the 19 May 2024, he was discharged home before a careline/lifeline pendant was provided .
At the inquest, the evidence of the manager of the Reablement team was that she did not know whether a careline had been installed at the time that Mr Franklin was found on the floor on the morning of the 28 May 2024. She informed the court that a Care Line had been requested for Mr Franklin on the 21 May 2024, and that on the 24 May 2024 during a physiotherapy assessment, Mr Franklin consented to a care line being ordered. The care notes reflected that a care line had been installed on the 22 May 2024.
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to confirm and communicate whether a careline had been installed
Wider context from the report “Mr Franklin lived alone and was assessed to be at high risk of falls. When he was discharged from Malvern Hospital on the 19 May 2024, he was discharged home before a careline/lifeline pendant was provided.
At the inquest, the evidence of the manager of the Reablement team was that she did not know whether a careline had been installed at the time that Mr Franklin was found on the floor on the morning of the 28 May 2024. She informed the court that a Care Line had been requested for Mr Franklin on the 21 May 2024, and that on the 24 May 2024 during a physiotherapy assessment, Mr Franklin consented to a care line being ordered. The care notes reflected that a care line had been installed on the 22 May 2024.
” Open source report
13 Sep 2022 Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 11 Delays in calling an ambulance when a resident’s condition requires emergency assistance View source Failure to maintain records of medications dispensed to residents View source Failure to record required twice-daily oral-cavity checks View source Ineffective investigation of resident deaths View source Failure to ensure effective supervision of nursing staff View source Failure to materially improve senior management oversight of the Registered Manager and deputy manager View source Failure to improve record keeping and record retention View source Failure to provide accurate and comprehensive audit information View source Shortcomings in senior management oversight of the Registered Manager View source Failure to ensure that all medications are recorded View source Failure to complete nursing records of residents’ medical conditions View source See 8 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
Mr Peter Antony Joseph Pearson · 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 Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Delays in calling an ambulance when a resident’s condition requires emergency assistance
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity .
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain records of medications dispensed to residents
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity.
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to record required twice-daily oral-cavity checks
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity.
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Ineffective investigation of resident deaths
Wider context from the report “(3) It is accepted on behalf of the Home that there was an “ineffective investigation” into Mr Pearson’s death by the Home . Responsibility for that cannot not solely be attributed to the former Registered Manager.
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective supervision of nursing staff
Wider context from the report “(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff .
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to materially improve senior management oversight of the Registered Manager and deputy manager
Wider context from the report “(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially . Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to improve record keeping and record retention
Wider context from the report “(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff.
” Open source report × Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate and comprehensive audit information
Wider context from the report “(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection ”. It is accepted by senior management that there were “shortcomings” in oversight of this manager. The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded.
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Shortcomings in senior management oversight of the Registered Manager
Wider context from the report “(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection”. It is accepted by senior management that there were “shortcomings” in oversight of this manager . The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded.
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all medications are recorded
Wider context from the report “(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection”. It is accepted by senior management that there were “shortcomings” in oversight of this manager. The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded .
” 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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to complete nursing records of residents’ medical conditions
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day . Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity.
” Open source report
5 Nov 2018 Gareth James Jones · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Failure to maintain the road surface to the specified highways-agency standard 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
Gareth James Jones · 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
Gareth James Jones died on the A422 at Inkberrow after losing control of the car he was driving and colliding with another vehicle. Concerns included previous road traffic deaths at the location, a road surface below the specified standard for three years, and the likelihood that the road surface contributed to the death.
Read the report on judiciary.uk
× Source evidence
How this individual concern was interpreted PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain the road surface to the specified highways-agency standard
Wider context from the report “(1) This is not the first road traffic 1st death at this location
(2) The traffic collision investigator's report (attached) indicates that the standard of the road surface has for 3 years been below that specified by the highways agency.
(3) The condition of the road surface is likely to have played a part in this death
” Open source report
22 Jul 2015 James Gerard McGEOWN · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 1 Road-surface undulation causing loss of control at higher speeds 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
James Gerard McGEOWN · 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
James Gerard McGEOWN died following a road traffic collision after overtaking at well over the 70mph speed limit while under the influence of alcohol and not wearing a seat belt. A road-surface undulation was identified as a potential concern because, at higher speeds, it could cause loss of control and may have contributed to the collision.
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 Worcestershire County Council; that does not assign responsibility.
PFD Monitor interpretation Road-surface undulation causing loss of control at higher speeds
Wider context from the report “(1) I enclose a copy of the Collision Investigator's Report, prepared by ████████, I draw your attention to paragraphs 6.13 and 8.6. ████████ has identified an "undulation" in the road surface. It is likely that this caused the "wobble" seen by the witness immediately prior to Mr McGeown losing control of his vehicle.
In his evidence to the Court, ████████ said that he had driven this stretch of road on several occasions as a consequence of this incident. While travelling within the speed limit the undulation causes drivers no concern. At higher speeds (95mph), ████████ described the undulation as causing a loss of control that may have caused an unsuspecting driver to have a collision.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations