PFD report

Charles Cecil Lawrence · Prevention of Future Deaths report

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Issued 25 Jul 2014•Portsmouth and South East Hampshire

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
1

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

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Concerns raised1

  1. Lack of a protocol for doctor examination of residents after more than one fall in a 24-hour period
    Part of recurring concern: Unreliable post-fall assessment and clinical response
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.2

  1. Action

    Implement a falls-alert process notifying residents’ surgeries after repeated falls, using fax notification for the agreed practice and direct calls for other surgeries.

    Stated by Alexandra Rose Residential Care HomeStated in progressThe respondent said that this action was in progress when they made their response on 25 July 2014.
  2. Action

    Add the falls-alert protocol to every resident’s care plan under mobility and falls-risk assessments.

    Stated by Alexandra Rose Residential Care HomeStated completedThe respondent said that this action was complete when they made their response on 25 July 2014.

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 a protocol for doctor examination of residents after more than one fall in a 24-hour period

Wider context from the report

“Alexandra Rose Care Home does not have a protocol of calling out a doctor to examine a resident who suffers more than one fall in a 24 hour period. ”

Is this part of a recurring concern?

Yes — Unreliable post-fall assessment and clinical 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

Implement a falls-alert process notifying residents’ surgeries after repeated falls, using fax notification for the agreed practice and direct calls for other surgeries.

Verbatim wording from the response

“The home has devised a ‘falls alert’ notification that will be faxed to the residents doctors surgery should they fall more than once over a 24 hour period. This has been agreed by the Drayton Medical Practice, although I have not as yet received any further response from the two other surgeries that the home uses. In this case the home will call these surgeries direct should a second fall arise within that period. We currently have over 25 residents registered at Drayton Medical Practice which is a substantial amount so I hope that you agree that this is the most important surgery to support us with this protocol.”

Source location

2014-0342-Response-by-Alexandra-Rose-Residential-Care-Home
Page 1 · response
Published 25 July 2014

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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

Add the falls-alert protocol to every resident’s care plan under mobility and falls-risk assessments.

Verbatim wording from the response

“Further to this document, each resident now has this Protocol in their care plans under there mobility and falls risk assessments.”

Source location

2014-0342-Response-by-Alexandra-Rose-Residential-Care-Home
Page 1 · response
Published 25 July 2014

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