PFD report

Ross Robson · Prevention of Future Deaths report

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Issued 23 May 2014•Milton Keynes

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
1

Of 1 recipient

Stated actions
1

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 place people in settings appropriate for their needs
    Part of recurring concern: Failure to ensure people are placed in care settings suitable for their needs
  2. Lack of adequate assessment of individual needs
    Part of recurring concern: Inadequate assessment of care needs before accepting patients into care
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.1

  1. Action

    Ensure social care team managers discuss respite-bed use, clear assessment, and support planning with their teams.

    Stated by Community WellbeingStated plannedThe respondent said that this action was planned when they made their response on 23 May 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The temporary placement was appropriate and did not result from inadequate assessment or support planning.

    Stated by Community WellbeingDisputes 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 place people in settings appropriate for their needs

Wider context from the report

“Ross Boyd was admitted to the Willows without an adequate assessment as to his needs being carried out with the result that he was placed at the Willows that was totally inappropriate for his needs. ”

Is this part of a recurring concern?

Yes — Failure to ensure people are placed in care settings suitable for their needs.

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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 adequate assessment of individual needs

Wider context from the report

“Ross Boyd was admitted to the Willows without an adequate assessment as to his needs being carried out with the result that he was placed at the Willows that was totally inappropriate for his needs. ”

Is this part of a recurring concern?

Yes — Inadequate assessment of care needs before accepting patients into care.

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

Ensure social care team managers discuss respite-bed use, clear assessment, and support planning with their teams.

Verbatim wording from the response

“In summary Mr Boyd’s placement at the Willows was made in an emergency as he was not managing at home and he, his family, and professionals involved believed a period of respite was in the best interests. Although it became apparent the Willows had difficulties meeting all of his needs I do not find that this was because of inadequate assessment prior to the placement. The Willows is a well-regarded care home and Adult Social Care use our contracted respite beds in the Centre for emergency care when required. I will ensure that managers of the social care teams discuss the use of respite beds with their teams and the need for clear assessment and support planning.”

Source location

2014-0313-Response-by-Milton-Keynes-Council
Page 2 · response
Published 23 May 2014

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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 temporary placement was appropriate and did not result from inadequate assessment or support planning.

Verbatim wording from the response

“An assessment of Mr Boyd’s needs was conducted on 4 October 2013 by ████████ and a care package at home was provided; additionally there was involvement and assessment from Community Occupational Therapy, Physiotherapy and the Rapid Assessment Team (RAIT) which is part of intermediate care. The District nurses were visiting and reviewed Mr Boyd’s medication and ████████ visited regularly. The decision to move Mr Boyd was based on his deterioration at home and increased risks to his wellbeing which included increased difficulties with transfers and falls which, at that time, did not appear to require a hospital admission or a specific health intervention. The decision was taken in consultation with Mr Boyd, and his family and other professionals involved.”

Source location

2014-0313-Response-by-Milton-Keynes-Council
Page 1 · response
Published 23 May 2014

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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

Continued falls were not caused by the type of care and support provided at the care centre.

Verbatim wording from the response

“when he was in the Willows however it is not apparent that this was in any way due to the type of care and support he received when staying there. Mr Boyd continued to try to transfer from his wheelchair unaided and did not use his pendant to call the care staff for assistance hence putting himself at risk of injury.”

Source location

2014-0313-Response-by-Milton-Keynes-Council
Page 2 · response
Published 23 May 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