Concerns raised 15 Failure to report falls View source Insufficiently robust auditing of care and safety omissions View source Failure to record falls View source Failure to hand over falls View source Failure to maintain complete, signed, dated and reviewed care plans View source Failure to ensure record-making staff can record effectively and independently View source Lack of falls risk assessments View source Lack of clarity about responsibility for initial bed rails assessments View source Insufficient night-time staffing for residents requiring assistance from two carers View source Failure to assess mental capacity View source Lack of bed rails assessments View source Failure to refer bed rails questions to Derbyshire Community Health View source Lack of clarity about staff responsibilities for handing over, recording and reporting falls View source Failure to refer residents to the Falls Team View source Failure to provide formal paid handover time within staff shifts View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 12
Action
Use a multifactorial falls risk assessment covering nighttime risks.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Improve recording and follow-up of bed-rail referrals so outstanding referrals are flagged.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Introduce company-wide basic literacy and numeracy testing, providing additional support and guidance where needed.
Stated plannedThe respondent said that this action was planned when they made their response on 4 December 2015. View source
Action
Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Clarify Horton Suite admission criteria to restrict admission to reasonably independent, low-falls-risk residents.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Train remaining key personnel on required procedures and resident documentation, with systems to monitor, audit and review effectiveness.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Provide a minimum of four staff across the building when a Horton Suite resident requires support from two carers.
Stated plannedThe respondent said that this action was planned when they made their response on 4 December 2015. View source
Action
Alter shift patterns to create overlap for a protected, paid handover.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Employ a Quality Manager to audit care homes, monitor managers’ auditing, and address omissions through quality-improvement action plans.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Use a care plan matrix assigning responsibility for reviewing individual care plans and monitor staff compliance.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source
Action
Clarify staff responsibility for initial bed-rail assessments and verify completion through care-plan audits.
Stated completedThe respondent said that this action was complete when they made their response on 4 December 2015. View source See 9 more actions
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AI-generated summary
Elsie Marjorie Brown · 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
Elsie Marjorie Brown fell from her bed at Langwith Lodge Residential Care Home on 23 March 2015, suffering fractures to her left humerus and right hip. She died in hospital on 5 April 2015 from bronchopneumonia and lobar pneumonia, which developed as a result of the fractures. Concerns included the absence of falls-risk and bed-rails assessments, an incomplete and unreviewed care plan, unclear responsibilities, inadequate recording and handovers, insufficient auditing, and potentially inadequate night staffing.
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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to report falls
Wider context from the report “6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported , and there was a lack of clarity amongst staff as to where responsibilities for these matters rested.
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficiently robust auditing of care and safety omissions
Wider context from the report “5. There was an insufficiently robust auditing process , in that the omissions were not identified by Langwith Lodge nor by Your Health Ltd.
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record falls
Wider context from the report “6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested.
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to hand over falls
Wider context from the report “6. Mrs Brown’s fall on 23rd March 2013 was not handed over , nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested.
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain complete, signed, dated and reviewed care plans
Wider context from the report “2. Mrs Brown’s care plan was incomplete, unsigned, undated and never reviewed , despite Mrs Brown falling from her bed on 8th March 2015.
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure record-making staff can record effectively and independently
Wider context from the report “7. A member of staff who had responsibility for record making could not effectively and independently do so due to poor literacy skills .
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of falls risk assessments
Wider context from the report “1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed.
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about responsibility for initial bed rails assessments
Wider context from the report “4. There was a lack of clarity as to where the responsibility for an initial bed rails assessment lay .
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient night-time staffing for residents requiring assistance from two carers
Wider context from the report “8. That the night time provision of two staff members to cover the main Lodge and two to cover the Horton Suite (two separate but joined buildings) was not seen as a minimum requirement to ensure the health and safety of residents when at least one resident in each building needed the assistance of two carers, but that only three were regularly rostered for the night shift .
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to assess mental capacity
Wider context from the report “1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed .
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of bed rails assessments
Wider context from the report “1. There was no falls risk assessment nor bed rails assessment in place for Mrs Brown, nor was her mental capacity assessed.
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to refer bed rails questions to Derbyshire Community Health
Wider context from the report “3. No referral was made to the Falls Team nor (by Langwith Lodge) to Derbyshire Community Health as regards the question of bed rails .
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity about staff responsibilities for handing over, recording and reporting falls
Wider context from the report “6. Mrs Brown’s fall on 23rd March 2013 was not handed over, nor recorded nor reported, and there was a lack of clarity amongst staff as to where responsibilities for these matters rested .
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to refer residents to the Falls Team
Wider context from the report “3. No referral was made to the Falls Team nor (by Langwith Lodge) to Derbyshire Community Health as regards the question of bed rails.
” 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 Your Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide formal paid handover time within staff shifts
Wider context from the report “9. Handovers were not regarded as integral to the staff’s paid shift and were informal and unpaid .
” 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 Use a multifactorial falls risk assessment covering nighttime risks.
Verbatim wording from the response “The Company did have corporate documentation in relation to falls risk assessment at the time of the incident. The ‘Multi-factorial falls risk assessment’ (attached) was introduced in 2014. This documentation allows Senior and Managerial staff to assess the likelihood of a resident suffering a fall and includes a section about the risks at night time.” Source location Elsie-Brown-Response
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 Improve recording and follow-up of bed-rail referrals so outstanding referrals are flagged.
Verbatim wording from the response “We would have expected a referral to have been responded to within 5-7 days, and at the time of the second incident on 23rd March 2015, no visit had been made. Since the inquest we have improved the system for recording when bed rail referrals have been made and how they are followed up. The new system should ensure that outstanding referrals are flagged up.” Source location Elsie-Brown-Response
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 Introduce company-wide basic literacy and numeracy testing, providing additional support and guidance where needed.
Verbatim wording from the response “However, as good practice we are introducing an internal basic literacy and numeracy test for all staff from 1st April 2016 across the company. This will ensure that all staff have adequate skills to facilitate excellent record keeping. Those who struggle with this process will not be discriminated against, but will receive extra support and guidance.” Source location Elsie-Brown-Response
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 Introduce a staff handover document recording daily responsibilities and identifying the senior person in charge.
Verbatim wording from the response “The Company has noted that there was some confusion as to who had overall responsibility when 2 senior staff were on duty and we introduced a staff handover document in September 2015 (attached) to document the daily responsibilities of individual staff on duty, as well as clearly outlining who the senior staff on duty were, and who was ultimately in charge of running the home.” Source location Elsie-Brown-Response
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 Use a falls management folder containing assessment tools, including a bed-rail risk assessment and algorithm.
Verbatim wording from the response “A falls management folder was introduced at Langwith in April 2015, which contains a number of different assessment tools to assist staff in reviewing the safety of a resident who is at risk of falls. This includes a specific bed rail risk assessment and algorithm (attached).” Source location Elsie-Brown-Response
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 Clarify Horton Suite admission criteria to restrict admission to reasonably independent, low-falls-risk residents.
Verbatim wording from the response “We take note of the Coroner’s recommendations and have clarified the criteria for admissions to the Horton suite so that safety levels are maintained. The Horton suite only caters for residents that are reasonably independent (require the support of one carer, if any) and are at low risk of falls. We do not intend having residents that require the support of 2 staff on the Horton suite but, in the rare circumstances that this could occur, we will ensure that we have a minimum of 4 staff on duty throughout the building to ensure that both areas of the home have adequate support.” Source location Elsie-Brown-Response
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 Train remaining key personnel on required procedures and resident documentation, with systems to monitor, audit and review effectiveness.
Verbatim wording from the response “The Company appointed an independent consultant in December 2015 to carry out an investigation into matters that had come to light during the course of the inquest. Part of this investigation looked into why this, and other corporate documentation was not used as part of Mrs Brown’s care plan. The Company has now taken appropriate disciplinary action and a large amount of work has been undertaken with remaining key personnel to ensure they understand the procedures and are conversant with appropriate documentation that should be used throughout a resident’s stay at one of our homes. There are also systems in place to ensure these are monitored, audited and reviewed for their effectiveness (see 2 below)” Source location Elsie-Brown-Response
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 Provide a minimum of four staff across the building when a Horton Suite resident requires support from two carers.
Verbatim wording from the response “We take note of the Coroner’s recommendations and have clarified the criteria for admissions to the Horton suite so that safety levels are maintained. The Horton suite only caters for residents that are reasonably independent (require the support of one carer, if any) and are at low risk of falls. We do not intend having residents that require the support of 2 staff on the Horton suite but, in the rare circumstances that this could occur, we will ensure that we have a minimum of 4 staff on duty throughout the building to ensure that both areas of the home have adequate support.” Source location Elsie-Brown-Response
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 Alter shift patterns to create overlap for a protected, paid handover.
Verbatim wording from the response “The Company has always recognised the importance of handovers as part of the daily routine for operating a service that runs 24 hours a day, 365 days a year. We are keen to ensure that the handover is a protected part of the day and is not interrupted in any way. We have consulted with staff and altered their shift patterns with effect from 21st January 2015, to ensure that we have an overlap of shifts which allows for a paid handover to take place to relay information about the people we are provided care and support to. We feel this will formalise the current system and make our handover process more robust.” Source location Elsie-Brown-Response
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 Employ a Quality Manager to audit care homes, monitor managers’ auditing, and address omissions through quality-improvement action plans.
Verbatim wording from the response “We recruited a Quality Manager in September 2015 who undertakes quality audits at all of our homes to ensure procedures are being followed and care plans are being compiled in a timely manner. All quality audits are supported by an action plan to ensure we continue to make improvements where necessary.” Source location Elsie-Brown-Response
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 Use a care plan matrix assigning responsibility for reviewing individual care plans and monitor staff compliance.
Verbatim wording from the response “The Company has always had clear guidance for all staff on the compiling of care plan documentation in a timely manner. As part of our ongoing quality improvement plan we introduced a care plan matrix in October 2015 (attached), which outlines which staff are responsible for reviewing which individual care plans and this is monitored by the management team to ensure all staff are fulfilling their individual duties.” Source location Elsie-Brown-Response
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 Clarify staff responsibility for initial bed-rail assessments and verify completion through care-plan audits.
Verbatim wording from the response “The Company introduced a falls management folder in April 2015, which includes an algorithm and risk assessment for bed rails (See 2 above). Following on from this, if necessary, the care home would make a recommendation for bed rails to the local health service through a referral. An Occupational Therapist or District Nurse then visits the home and makes a decision on whether bed rails can be used to reduce the risk of the resident falling out of bed. Other alternatives are also considered.” Source location Elsie-Brown-Response
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 staff member’s literacy was considered adequate because records showed they had passed a basic literacy test and an accredited care qualification.
Verbatim wording from the response “Our records show that the staff member concerned had passed a basic literacy test, as part of the entry requirement for being enrolled on a course in Health and Social Care (NVQ level 2) with an Accredited training provider, which they passed. We were therefore satisfied that their literacy was of an adequate standard.” Source location Elsie-Brown-Response
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 A formal capacity assessment was not considered necessary because capacity was presumed unless evidence showed that Mrs Brown lacked capacity.
Verbatim wording from the response “The Company also, since 2010, have had corporate documentation and procedures in place to assess the mental capacity of residents. These are regularly updated, eg when there are changes in legislation. Mrs Brown’s capacity was not formally assessed as it was not deemed that she lacked capacity, and the Mental Capacity Act states that capacity must always be assumed unless it is proved otherwise.” Source location Elsie-Brown-Response
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 Four night staff were not considered routinely necessary because the two areas formed one linked building and staffing levels were based on residents’ dependency.
Verbatim wording from the response “Langwith Lodge Residential Home has two named areas but is one building and everything in the main ‘Lodge’ is linked with the ‘Horton Suite’. All the systems that make the home safe, such as fire alarms and the ‘carer assist system’, (colloquially called ‘nurse call’), work equally in all areas of the home and are linked together, so staff across the building know when someone requires assistance. The Horton suite is accessible both at the front and rear of the main lodge through internal doors. We have the two identified areas to distinguish between the ‘traditional care home’ and the Horton suite which is marketed to more independent residents. Dependency checks are completed for all residents to support safe staffing numbers.” Source location Elsie-Brown-Response
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 local health service was responsible for providing bed rails, with an occupational therapist or district nurse deciding whether they could be used.
Verbatim wording from the response “Bed rail referrals have always been made via the nurse practitioner, Claire Byrnes to Derbyshire Community Health. It is the responsibility of the local health service to provide bed rails and we were awaiting an OT visit to the home to make a decision on them being used.” Source location Elsie-Brown-Response
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations