PFD report

Name not published · Prevention of Future Deaths report

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Issued 29 Nov 2016•County Durham and Darlington

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.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

Stated actions
3

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 raised2

  1. Failure to identify unsuitable mattresses for care recipients
    Part of recurring concern: Failure to ensure mattresses are suitable for care recipients and beds
  2. Lack of risk assessment for falls and pressure sore risk
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Inadequate management of pressure ulcers
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

    Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.

    Stated by Lambton HouseStated in progressThe respondent said that this action was in progress when they made their response on 26 February 2017.
  2. Action

    Install pressure mats whenever a mattress is incompatible with bed sensors.

    Stated by Lambton HouseStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.

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 identify unsuitable mattresses for care recipients

Wider context from the report

“(2) It became apparent that the new mattress was not suitable for the deceased and that this had not been adequately identified. ”

Is this part of a recurring concern?

Yes — Failure to ensure mattresses are suitable for care recipients and beds.

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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

Lack of risk assessment for falls and pressure sore risk

Wider context from the report

“(1) It became apparent that a risk assessment was not completed in relation to the deceased's falls and the pressure sore risk. The deceased was found on the floor after an unwitnessed night by a carer at approximately 4.00 hours. She sustained injuries which subsequently led to her death. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Inadequate management of pressure ulcers.

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

Phase in air-flow mattresses through Home Loans for residents with an assessed need for pressure-relief care.

Verbatim wording from the response

“Steps are being taken to further minimise the risk that resident's face in situations such as this. Lambton House is currently in the process of phasing in through “Home Loans” the provision of air flow mattresses, where there has been an assessed need to aid pressure relief care. All new air flow mattresses are compatible with bed based pressure sensors. The aim is to eliminate the need for floor based pressure sensors, which in themselves can also create a risk of falls/trips.”

Source location

2016-0423-Response-by-Lambton-House-Care-Home
Page 1 · response
Published 26 February 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

Install pressure mats whenever a mattress is incompatible with bed sensors.

Verbatim wording from the response

“Staff at Lambton House did recognise that a pressure sensor needed to be placed next to the deceased's bed and attempts were made to try to have a floor pressure sensor mat installed next to the deceased's bed. Unfortunately at that time this required a specialist contractor to attend to install the mat and incorporate it into the building's existing alarm system. That change could not take place that day. Unfortunately the deceased suffered a fall later that evening. It is now standard practice for pressure mats to be installed in all cases where a mattress is used that is incompatible with bed sensors.”

Source location

2016-0423-Response-by-Lambton-House-Care-Home
Page 1 · response
Published 26 February 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.1

  1. 1

    Install bed sensors for service users at risk of falls who do not require an air-flow mattress.

    Stated by Lambton HouseStated completedThe respondent said that this action was complete when they made their response on 26 February 2017.

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

  1. 1

    The absence of a pressure sensor did not contribute to the fall or affect injury severity, and pressure mats do not eliminate fall risk.

    Stated by Lambton HouseDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Install bed sensors for service users at risk of falls who do not require an air-flow mattress.

Verbatim wording from the response

“For those Service Users who are at risk of falls but do not require an air flow mattress a bed sensor is installed to reduce the risk.”

Source location

2016-0423-Response-by-Lambton-House-Care-Home
Page 1 · response
Published 26 February 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 absence of a pressure sensor did not contribute to the fall or affect injury severity, and pressure mats do not eliminate fall risk.

Verbatim wording from the response

“Lambton House believe that the Coroner has found that the simple provision of a pressure mat by a resident's bed will not eliminate their risk of falls, rather, it will simply alert staff that a resident is out of bed sooner and that this may lead to a reduction in the risk of fatalities. Lambton House confirm that there is no evidence to suggest that the absence of a pressure mat sensor in anyway contributed to the deceased's fall nor did it impact on the severity of the injuries that she sustained as a result of the fall.”

Source location

2016-0423-Response-by-Lambton-House-Care-Home
Page 1 · response
Published 26 February 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