PFD report

Sybil Roberts · Prevention of Future Deaths report

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Issued 12 Sep 2014•North Wales (East and Central)

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 raised2

  1. Failure to obtain further falls risk assessments when residents’ condition is declining
    Part of recurring concern: Inadequate control of falls risks
  2. Failure to reassess and update care plans and falls risks after hospital return
    Part of recurring concern: Failure to reliably develop and review risk-reduction plansPart of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable care-planning processesPart of recurring concern: Unreliable return-from-hospital arrangements
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 obtain further falls risk assessments when residents’ condition is declining

Wider context from the report

“During the course of the investigation it became apparent that although Mrs Roberts had been assessed upon her admission to the residential home, there had not been a referral to her GP (as would be normal practice at this home) for a further falls risk assessment. This is despite an acknowledgement that her condition was declining prior to the first fall. Furthermore her care plan and falls risk had not been reassessed and updated prior to her return to the home from hospital after the first fall and she sustained her second fracture only two days later. An inadequate assessment of the potential risks Mrs Roberts was made and 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 — Inadequate control of falls risks.

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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 reassess and update care plans and falls risks after hospital return

Wider context from the report

“During the course of the investigation it became apparent that although Mrs Roberts had been assessed upon her admission to the residential home, there had not been a referral to her GP (as would be normal practice at this home) for a further falls risk assessment. This is despite an acknowledgement that her condition was declining prior to the first fall. Furthermore her care plan and falls risk had not been reassessed and updated prior to her return to the home from hospital after the first fall and she sustained her second fracture only two days later. An inadequate assessment of the potential risks Mrs Roberts was made and 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 develop and review risk-reduction plans; Inadequate control of falls risks; Unreliable care-planning processes; Unreliable return-from-hospital arrangements.

Open source report
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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