Annie Ceinwen Jones · Prevention of Future Deaths report

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Issued 20 Nov 2013•North Wales (East and Central)

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised4

  1. Inadequate assessment of patient mobility
    Part of recurring concern: Failure to assess and meet patients’ mobility needs
  2. Failure of staff to operate stand aids safely
  3. Failure of staff to be aware of patients' mobility limitations
    Part of recurring concern: Failure to reliably identify and communicate individual patient risk factors

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.5

  1. Abbey Dale House

    Create an accessible resident mobility summary and person-handling plan for all care staff, including new and agency staff.

  2. Abbey Dale House

    Add staff and assessor sign-off sections documenting competence with each item of manual-handling equipment.

  3. Abbey Dale House

    Complete specialised train-the-trainer education covering manual handling and person-handling risk assessments.

  4. Abbey Dale House

    Improve the completeness and legibility of mobility risk-assessment paperwork.

  5. Abbey Dale House

    Adopt the All-Wales Manual Handling Passport training programme, including person-handling modules.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Abbey Dale House

    The resident did not fall; she slipped down the sling, which held her, and medication exacerbated the resulting bruising.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  2. Abbey Dale House

    The stand-aid was not considered unsafe because it had been successfully used, formally reviewed monthly, and supported by staff assessments.

    Disputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. Abbey Dale House

    The resident was unable to walk but could partially weight-bear sufficiently to transfer using the stand-aid.

    Disputes 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

Inadequate assessment of patient mobility

Wider context from the report

“During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years. 1. An inadequate assessment of the mobility of Mrs Jones was made 2. The stand aid was unsafe for use with Mrs Jones 3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility 4. Not all staff were able to operate the stand safely. Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”

Is this part of a recurring concern?

Yes — Failure to assess and meet patients’ mobility needs.

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 staff to operate stand aids safely

Wider context from the report

“During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years. 1. An inadequate assessment of the mobility of Mrs Jones was made 2. The stand aid was unsafe for use with Mrs Jones 3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility 4. Not all staff were able to operate the stand safely. Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”

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 of staff to be aware of patients' mobility limitations

Wider context from the report

“During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years. 1. An inadequate assessment of the mobility of Mrs Jones was made 2. The stand aid was unsafe for use with Mrs Jones 3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility 4. Not all staff were able to operate the stand safely. Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”

Is this part of a recurring concern?

Yes — Failure to reliably identify and communicate individual patient risk factors.

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

Use of an unsafe stand aid for non-weight-bearing patients

Wider context from the report

“During the course of the investigation it became apparent that Mrs Jones had sustained severe bruising to her upper body following the fall referred to in paragraph 4 and that she should never have been placed in this "stand aid" which required her to some extent weight bearing. Mrs Jones had not been weight bearing for over three years. 1. An inadequate assessment of the mobility of Mrs Jones was made 2. The stand aid was unsafe for use with Mrs Jones 3. Not all staff were aware of the limitations of Mrs Jones with regard to her mobility 4. Not all staff were able to operate the stand safely. Whilst the incident did not contribute to this death I feel it is necessary to bring this to your attention due to the fragile and vulnerable nature of other patients cared for at the home for whom an injury in these circumstances could result in death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Create an accessible resident mobility summary and person-handling plan for all care staff, including new and agency staff.

Verbatim wording from the response

“In order to overcome any communication issues with regards to manual-handling changes, and to provide a point of reference for all staff (including new/agency staff), an updated document has been created to provide a snapshot of each resident's needs, which includes a summary person handling plan, which is readily available to all care staff.”

Source location

2013-0306-Response-by-Abbey-Dale-House
Page 4 · response
Published 20 November 2013

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 staff and assessor sign-off sections documenting competence with each item of manual-handling equipment.

Verbatim wording from the response

“The improved documentation will include sections for staff and assessor to sign off that they are competent using each piece of manual handling equipment.”

Source location

2013-0306-Response-by-Abbey-Dale-House
Page 4 · response
Published 20 November 2013

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

Complete specialised train-the-trainer education covering manual handling and person-handling risk assessments.

Verbatim wording from the response

“Following this event, and to improve the provision of manual handling training within Abbey Dale House, I undertook a 4-day specialised Train-the-trainer course in February 2012, run by Edge Services, a national company that specialise in Manual Handling Training. This course also involved a risk assessment element to the course, to enable full manual handling and person handling risk assessments to be performed by myself.”

Source location

2013-0306-Response-by-Abbey-Dale-House
Page 3 · response
Published 20 November 2013

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

Improve the completeness and legibility of mobility risk-assessment paperwork.

Verbatim wording from the response

“We acknowledge that the paperwork accompanying the risk assessment was not as comprehensive or as legible as it could have been, and we have taken steps to overcome these issues.”

Source location

2013-0306-Response-by-Abbey-Dale-House
Page 3 · response
Published 20 November 2013

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

Adopt the All-Wales Manual Handling Passport training programme, including person-handling modules.

Verbatim wording from the response

“In order to improve this, Abbey Dale House has adopted the All-Wales Manual Handling Passport, which is an intensive manual-handling training programme and includes person handling modules.”

Source location

2013-0306-Response-by-Abbey-Dale-House
Page 4 · response
Published 20 November 2013

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 resident did not fall; she slipped down the sling, which held her, and medication exacerbated the resulting bruising.

Verbatim wording from the response

“In the report in section 4, which states “...with extensive bruising sustained in a fall from a "stand aid" ..... I wish to clarify that Mrs Jones did not suffer a "fall" as such, but slipped down the sling, which held her, and prevented her from falling to the floor. The sling which was used with the stand-aid has a strap across the chest area, which caused the bruising to her upper body, which was identified across her chest. Because of her medication, (prednisolone), this exacerbated her bruising, a common side-effect of this medication.”

Source location

2013-0306-Response-by-Abbey-Dale-House
Page 2 · response
Published 20 November 2013

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 stand-aid was not considered unsafe because it had been successfully used, formally reviewed monthly, and supported by staff assessments.

Verbatim wording from the response

“Mrs Jones had successfully used this particular equipment since the original assessment in March 2012, and the manual handling plan was formally reviewed monthly. On each occasion that any resident is transferred with equipment, the staff have to assess their ability to follow instructions; and to also assess their physical capabilities, which can vary from day-to-day, and even from hour-to-hour.”

Source location

2013-0306-Response-by-Abbey-Dale-House
Page 3 · response
Published 20 November 2013

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 resident was unable to walk but could partially weight-bear sufficiently to transfer using the stand-aid.

Verbatim wording from the response

“In section 5, your report stated that Mrs Jones had not been weight-bearing for over three years. I believe that there has been some misunderstanding about this term. Mrs Jones had not been able to walk since she had been with us (since 23rd June 2010), but she was able to partially weight-bear - sufficiently to transfer with a stand-aid.”

Source location

2013-0306-Response-by-Abbey-Dale-House
Page 2 · response
Published 20 November 2013

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