PFD report

Maureen Patricia FLYNN · Prevention of Future Deaths report

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Issued 26 Aug 2016•Manchester South

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

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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

Source document

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 complete required falls risk assessments
    Part of recurring concern: Inadequate control of falls risks
  2. Failure of patient safety investigations to identify incomplete required assessments
  3. Lack of alerts to staff when required patient safety assessments are incomplete
    Part of recurring concern: Unreliable clinical safety-alert systemsPart of recurring concern: Unreliable patient risk-assessment processes
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 a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. Action

    Share the Coroner’s Inquest findings with Ward E2 staff and highlight the need to review falls risk assessments when bed-bound patients begin sitting out.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 August 2016.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The falls risk assessment was completed within six hours of Ward E2 arrival, contrary to the concern that it had not been completed.

    Stated by Stockport NHS Foundation TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 complete required falls risk assessments

Wider context from the report

“The evidence at the Inquest suggested that if, from the falls risk assessment, there were concerns as to Mrs Flynn’s mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover. However, as the assessment had not been completed out no-one knew, least of all the HCA. It is of concern to me that those caring for a patient were ignorant of the fact that Mrs Flynn’s falls risk assessment had not been completed. It is clear that the HCA was unaware. It is reasonable for staff, in my view, to assume that all assessments have been appropriately carried out and completed. Why would the HCA have thought otherwise given the high falls risk sign above Mrs Flynn’s bed? It would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed. My concern extends to any other assessment required for a patient’s safety and well-being. I am further concerned that the Patient Safety Investigation did not identify the fact that the falls risk assessment had not been completed. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 of patient safety investigations to identify incomplete required assessments

Wider context from the report

“The evidence at the Inquest suggested that if, from the falls risk assessment, there were concerns as to Mrs Flynn’s mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover. However, as the assessment had not been completed out no-one knew, least of all the HCA. It is of concern to me that those caring for a patient were ignorant of the fact that Mrs Flynn’s falls risk assessment had not been completed. It is clear that the HCA was unaware. It is reasonable for staff, in my view, to assume that all assessments have been appropriately carried out and completed. Why would the HCA have thought otherwise given the high falls risk sign above Mrs Flynn’s bed? It would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed. My concern extends to any other assessment required for a patient’s safety and well-being. I am further concerned that the Patient Safety Investigation did not identify the fact that the falls risk assessment had not been completed. ”

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

Lack of alerts to staff when required patient safety assessments are incomplete

Wider context from the report

“The evidence at the Inquest suggested that if, from the falls risk assessment, there were concerns as to Mrs Flynn’s mobilising in and out bed and/or in and out of her chair and her stability then these would have been highlighted in the nursing notes/care plan and discussed at any handover. However, as the assessment had not been completed out no-one knew, least of all the HCA. It is of concern to me that those caring for a patient were ignorant of the fact that Mrs Flynn’s falls risk assessment had not been completed. It is clear that the HCA was unaware. It is reasonable for staff, in my view, to assume that all assessments have been appropriately carried out and completed. Why would the HCA have thought otherwise given the high falls risk sign above Mrs Flynn’s bed? It would seem eminently sensible to adopt a system whereby staff are alerted to the fact that a falls risk assessment has not been completed. My concern extends to any other assessment required for a patient’s safety and well-being. I am further concerned that the Patient Safety Investigation did not identify the fact that the falls risk assessment had not been completed. ”

Is this part of a recurring concern?

Yes — Unreliable clinical safety-alert systems; Unreliable patient risk-assessment processes.

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

Share the Coroner’s Inquest findings with Ward E2 staff and highlight the need to review falls risk assessments when bed-bound patients begin sitting out.

Verbatim wording from the response

“Following the investigation, Ward E2 shared the findings of the investigation via their Newsletter in June 2016. Please see attached the June ward newsletter for your information (page 2). In August 2016, I can confirm that the findings of the Coroner's Inquest was shared on Ward E2 and attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair. Please see attached the August ward newsletter for your information (page 2).”

Source location

2016-0310-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 26 August 2016

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 falls risk assessment was completed within six hours of Ward E2 arrival, contrary to the concern that it had not been completed.

Verbatim wording from the response

“As confirmed above, the falls risk assessment had been completed within 6 hours of the patient's arrival to Ward E2 and this was in line with Trust policy. This assessment deemed the patient to be at risk of falls and bed rails were in situ. As the falls risk assessment was completed appropriately, this was not deemed to be a care or service delivery problem and therefore was not included within the Patient Safety Investigation report.”

Source location

2016-0310-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 26 August 2016

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.1

  1. 1

    Share the falls investigation findings with Ward E2 staff through the June 2016 ward newsletter.

    Stated by Stockport NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 26 August 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Existing visual assessments, safety huddles, electronic handover controls and fall sensors address changing falls risks and patient allocation.

    Stated by Stockport NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 the falls investigation findings with Ward E2 staff through the June 2016 ward newsletter.

Verbatim wording from the response

“Following the investigation, Ward E2 shared the findings of the investigation via their Newsletter in June 2016. Please see attached the June ward newsletter for your information (page 2). In August 2016, I can confirm that the findings of the Coroner's Inquest was shared on Ward E2 and attention drawn to the need for fall risk assessments to be reviewed when a bed-bound patient starts to sit out in a chair. Please see attached the August ward newsletter for your information (page 2).”

Source location

2016-0310-Response-by-Stockport-NHS-Trust
Page 3 · response
Published 26 August 2016

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

Existing visual assessments, safety huddles, electronic handover controls and fall sensors address changing falls risks and patient allocation.

Verbatim wording from the response

“Falls risk assessments are formally undertaken within six hours of arrival to the ward and thereafter every seven days unless the patient sustains a fall, a near-miss fall or their condition changes such that it would affect their falls risk. However, all staff undertake an informal visual assessment on each occasion that a patient is mobilised as a patient's condition, ability and compliance can vary especially in elderly patients. Patients at higher risk of falls are discussed twice daily at safety huddles (07:15 hours and 19:45 hours).”

Source location

2016-0310-Response-by-Stockport-NHS-Trust
Page 2 · response
Published 26 August 2016

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