PFD report

Helen Theresa Cannon · Prevention of Future Deaths report

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Issued 16 Aug 2017•Manchester West

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
5

Named on the report

Responses found
1

Of 5 recipients

Stated actions
5

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 ensure understanding of the meaning of countersigning risk assessment checklists
    Part of recurring concern: Inadequate safety incident investigationsPart of recurring concern: Unreliable completion and verification of falls-risk assessments
  2. Failure to seek medical or paramedic assistance when warranted by a person's condition
    Part of recurring concern: Failure to assess and respond promptly to significant signs of injuryPart of recurring concern: Failure to seek medical attention when a person's condition warrants it
  3. Failure to address inaccuracies in moving and handling risk assessment checklists during investigations
    Part of recurring concern: Inadequate safety incident investigations
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.3

  1. Action

    Integrate a pain-assessment profile into the client assessment process and review the revised process with the service committee.

    Stated by Eldercare (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 November 2017.
  2. Action

    Redesign the investigation checklist with STOP alerts, defined sections, clearer larger formatting, and clarified second-responder accuracy checks.

    Stated by Eldercare (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 November 2017.
  3. Action

    Add an internal review step to investigations while preserving employees’ rights to appeal after formal investigation.

    Stated by Eldercare (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 November 2017.

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

  1. Position

    The investigation was conducted with sufficient rigour and accuracy despite concerns about its thoroughness.

    Stated by Eldercare (UK) LimitedDisputes 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 ensure understanding of the meaning of countersigning risk assessment checklists

Wider context from the report

“2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it. It was his belief that he signed the checklist simply to agree that he had been present. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations; Unreliable completion and verification of falls-risk assessments.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Failure to seek medical or paramedic assistance when warranted by a person's condition

Wider context from the report

“1. The emergency responders did not seek medical or paramedic assistance for Mrs Cannon because she was complaining of suffering aching rather than pain. It transpired that Mrs Cannon had suffered internal haemorrhage as a result of a pelvic fracture sustained in her fall, and this led to her death two days later. Evidence was heard at the Inquest from a Consultant Trauma and Orthopaedic Surgeon that in the circumstances it would have been good practice to have obtained medical or paramedic assistance for Mrs Cannon. ”

Is this part of a recurring concern?

Yes — Failure to assess and respond promptly to significant signs of injury; Failure to seek medical attention when a person's condition warrants it.

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 address inaccuracies in moving and handling risk assessment checklists during investigations

Wider context from the report

“2. Following Mrs Cannon’s death Eldercare carried out an investigation. The investigation was flawed in that it did not address clear inaccuracies in the Moving and Handling Risk assessment checklist completed by one of the Emergency Responders, nor did it discover that the other Emergency Responder attending did not understand that he was agreeing with the accuracy of the information recorded on the checklist when he countersigned it. It was his belief that he signed the checklist simply to agree that he had been present. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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

Integrate a pain-assessment profile into the client assessment process and review the revised process with the service committee.

Verbatim wording from the response

“1. The seeking of medical assistance associated with the client expressing that she was “aching rather than in pain”. Presuming that a service can operate without the express requirement for a medical assessment, then the procedures in place at the time of the lady’s fall, the staff carried out an assessment of the client, and part of that assessment was to determine whether it was in pain. However it is clear from your concern that there is an ambiguity around the definition of ‘pain’ vs ‘ache’ and we agree that this could potentially blur the outcome of the evaluation. As a consequence a full review of the surrounding process of patient assessment and a ‘pain assessment profile questionnaire’ has been integrated within the process. This has been reviewed and agreed with the service committee at Wigan Council in order to seek their opinion and agreement as to its suitability.”

Source location

2017-0260-Response
Page 1 · response
Published 8 November 2017

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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

Redesign the investigation checklist with STOP alerts, defined sections, clearer larger formatting, and clarified second-responder accuracy checks.

Verbatim wording from the response

“2. With regard to the second concern expressed, namely the thoroughness of the investigation, we acknowledge, after further review of the documentation, that the review was conducted with the level of rigor and accuracy that the checklist has also been fully reviewed as part of (i) above. We have introduced “STOP” elements to alert the responders where their answers are such that further assistance may be necessary. We have also separated the checklist out into defined areas and made the layout of the checklist easier and larger which we believe will also assist the staff in completing the documentation. Additionally, the responsibility for the second responder to review the accuracy of a colleague’s client assessment has been clarified with all of the staff, and the timeline of the update has been agreed with Wigan Council.”

Source location

2017-0260-Response
Page 2 · response
Published 8 November 2017

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

Add an internal review step to investigations while preserving employees’ rights to appeal after formal investigation.

Verbatim wording from the response

“This has also been reflected within the re-design of the document. An additional step with regard to review was also been added to the internal company process of investigation in such cases, whilst still maintaining the integrity of the procedure in line with protecting the employee’s rights to appeal following a formal investigation. We believe that this will ensure that future investigations will deliver the required result.”

Source location

2017-0260-Response
Page 2 · response
Published 8 November 2017

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 investigation was conducted with sufficient rigour and accuracy despite concerns about its thoroughness.

Verbatim wording from the response

“2. With regard to the second concern expressed, namely the thoroughness of the investigation, we acknowledge, after further review of the documentation, that the review was conducted with the level of rigor and accuracy that the checklist has also been fully reviewed as part of (i) above. We have introduced “STOP” elements to alert the responders where their answers are such that further assistance may be necessary. We have also separated the checklist out into defined areas and made the layout of the checklist easier and larger which we believe will also assist the staff in completing the documentation. Additionally, the responsibility for the second responder to review the accuracy of a colleague’s client assessment has been clarified with all of the staff, and the timeline of the update has been agreed with Wigan Council.”

Source location

2017-0260-Response
Page 2 · response
Published 8 November 2017

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.2

  1. 1

    Work with Wigan Council to adopt and monitor the new processes for the service.

    Stated by Eldercare (UK) LimitedStated in progressThe respondent said that this action was in progress when they made their response on 8 November 2017.
  2. 2

    Implement revised moving-and-handling processes with enhanced documentation, an additional verification step, 24/7 control-centre support, staff dissemination, and dedicated training.

    Stated by Eldercare (UK) LimitedStated completedThe respondent said that this action was complete when they made their response on 8 November 2017.

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

Work with Wigan Council to adopt and monitor the new processes for the service.

Verbatim wording from the response

“We are working closely with Wigan Council to adopt and monitor the new processes with a view to achieving a workable and satisfactory outcome in the future for this service.”

Source location

2017-0260-Response
Page 2 · response
Published 8 November 2017

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 revised moving-and-handling processes with enhanced documentation, an additional verification step, 24/7 control-centre support, staff dissemination, and dedicated training.

Verbatim wording from the response

“As part of a service improvement process, a continual review to ensure that the new elements will deliver the desired outcome. Further to the above introduction of the pain profile, a number of amendments have been made to the overall moving and handling process; integrating improved support documentation and an additional verification step along with a 24/7 control centre. A copy of the process flowchart and the accompanying documentation associated with the assessment procedure can be made available if required. The revised processes have been disseminated to those members of staff whose responsibilities include the provision of moving and”

Source location

2017-0260-Response
Page 1 · response
Published 8 November 2017

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