Kathleen Smith · Prevention of Future Deaths report

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Issued 14 Nov 2017•Manchester South

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
2

Described in responses

Recipients and published responses

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised3

  1. Failure to audit or review incidents and issues after the departure of the responsible manager
  2. Failure to notify the corporate risk function of incident circumstances
    Part of recurring concern: Failure to maintain safety risks in corporate risk governance
  3. Internal incident reporting and escalation process depending largely on an individual manager
    Part of recurring concern: Unreliable reporting of patient-safety incidents

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.2

  1. Borough Care Ltd

    Ensure incidents are discussed during audit meetings involving the Quality Manager, Area Support team and Home Manager.

  2. Borough Care Ltd

    Implement a weekly significant-incident reporting form, discuss reported incidents at Care and Quality meetings, and action follow-up through Area Support.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to audit or review incidents and issues after the departure of the responsible manager

Wider context from the report

“In the course of the inquest I heard evidence that, whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained injury on 12th April 2017, neither the family nor Borough Care’s corporate risk function had been notified of the circumstances which led to Mrs Smith’s hip fracture. This latter point raises a particular concern as to Borough Care’s ability to undertake any meaningful investigation into the circumstances of Mrs Smith’s injury, with a view to deriving learning for the benefit of other residents. The inquest also heard evidence that Lisburne Court’s process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care’s employment. It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to notify the corporate risk function of incident circumstances

Wider context from the report

“In the course of the inquest I heard evidence that, whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained injury on 12th April 2017, neither the family nor Borough Care’s corporate risk function had been notified of the circumstances which led to Mrs Smith’s hip fracture. This latter point raises a particular concern as to Borough Care’s ability to undertake any meaningful investigation into the circumstances of Mrs Smith’s injury, with a view to deriving learning for the benefit of other residents. The inquest also heard evidence that Lisburne Court’s process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care’s employment. It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing. ”

Is this part of a recurring concern?

Yes — Failure to maintain safety risks in corporate risk governance.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Internal incident reporting and escalation process depending largely on an individual manager

Wider context from the report

“In the course of the inquest I heard evidence that, whilst the management team at Lisburne Court had notified Greater Manchester Police and Stockport Metropolitan Borough Council of the incident in which Mrs Smith sustained injury on 12th April 2017, neither the family nor Borough Care’s corporate risk function had been notified of the circumstances which led to Mrs Smith’s hip fracture. This latter point raises a particular concern as to Borough Care’s ability to undertake any meaningful investigation into the circumstances of Mrs Smith’s injury, with a view to deriving learning for the benefit of other residents. The inquest also heard evidence that Lisburne Court’s process for internal incident reporting and escalation largely fell to an individual manager who has since left Borough Care’s employment. It was a matter of concern that notwithstanding this fact, no audit or similar review exercise as to incidents or issues at Lisburne Court had been undertaken since the departure of the individual manager in question, despite the evidence of the Interim Head of Care that some resident documentation and computer files has allegedly gone missing. ”

Is this part of a recurring concern?

Yes — Unreliable reporting of patient-safety incidents.

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

Ensure incidents are discussed during audit meetings involving the Quality Manager, Area Support team and Home Manager.

Verbatim wording from the response

“Our Quality Manager and Area support team will also ensure that any incidents are discussed on their audit meetings with the Home Manager.”

Source location

2017-0397-Response-by-Borough-Care
Page 1 · response
Published 15 February 2018

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 a weekly significant-incident reporting form, discuss reported incidents at Care and Quality meetings, and action follow-up through Area Support.

Verbatim wording from the response

“I have therefore devised a form that managers must complete on a weekly basis to inform Head of Care of any significant incidents that happen in the home. These incidents are discussed weekly at our Care & Quality meetings and any follow up is actioned by the Area Support for that Home. This form was introduced to all Managers on the 26th October at our monthly Managers meeting and was actioned by the Managers from the following Monday.”

Source location

2017-0397-Response-by-Borough-Care
Page 1 · response
Published 15 February 2018

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026