PFD report

Alois Piska · Prevention of Future Deaths report

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Issued 23 Dec 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
3

Named on the report

Responses found
1

Of 3 recipients

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

Select any concern, action or position to view the source wording.

Concerns raised1

  1. Inadequate staffing to supervise residents in communal areas during use
    Part of recurring concern: Failure to reliably supervise and monitor residents in care accommodation
Responses linked to these concerns

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

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Staffing levels were not inadequate; the unit was over-staffed against industry averages and had appropriate numbers to meet residents’ needs.

    Stated by Care UK Community Partnerships LtdDisputes 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 staffing to supervise residents in communal areas during use

Wider context from the report

“There were inadequate numbers of staff at Harry Sotnick House to supervise residents in communal areas at all times when such areas are in use. ”

Is this part of a recurring concern?

Yes — Failure to reliably supervise and monitor residents in care accommodation.

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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

Staffing levels were not inadequate; the unit was over-staffed against industry averages and had appropriate numbers to meet residents’ needs.

Verbatim wording from the response

“On the 29th May I can confirm that the occupancy of the unit in question was 15 residents. The staff deployed to support these residents were: 1 Registered Nurse and 5 care staff which is a ratio of 1 member of staff to 2.5 residents.”

Source location

2014-0553-Response-by-Care-Uk
Page 1 · response
Published 23 December 2014

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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.2

  1. 1

    Complete falls risk assessments for every resident and update them monthly to determine appropriate care and support.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 23 December 2014.
  2. 2

    Train staff not to catch residents during falls, reducing injury risk to residents and staff.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 23 December 2014.

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

  1. 1

    Staff presence would not necessarily have prevented the fall because falls are unpredictable and staff are trained not to catch falling residents.

    Stated by Care UK Community Partnerships LtdDisputes 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

Complete falls risk assessments for every resident and update them monthly to determine appropriate care and support.

Verbatim wording from the response

“Risk assessments for falls are completed on every resident in the home and updated monthly. These assessments consider gender, age, falls history, sensory deficits, medication, medical history, mobility and gait. The assessment scores a risk and puts them into a high, medium or low category. Depending on the category, then depends on the care and the support that they are provided with e.g. review medication, physiotherapy, opticians, etc. Mr Piska was classified ‘low’ as it was indicated in the plan of care that he was not mobile.”

Source location

2014-0553-Response-by-Care-Uk
Page 2 · response
Published 23 December 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

Train staff not to catch residents during falls, reducing injury risk to residents and staff.

Verbatim wording from the response

“Staff members are trained not to catch residents if they fall. This is to prevent injury to both resident and staff member. Therefore, even if a member of staff was present when Mr Piska fell, they would not have been able to prevent him from falling. On the 29th May it is my view that there were appropriate numbers of staff in the unit in question to meet the needs of the residents at that time.”

Source location

2014-0553-Response-by-Care-Uk
Page 2 · response
Published 23 December 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

Staff presence would not necessarily have prevented the fall because falls are unpredictable and staff are trained not to catch falling residents.

Verbatim wording from the response

“Staff are deployed in the unit based on the identified needs of the residents. We do advocate that when clients are sat in communal areas there is a member of staff to support them. Due to the unpredictability and the nature of the Dementia disease it is extremely difficult to anticipate when a client may attempt to mobilise and subsequently have a fall in any area of the home, be it a communal area or their room.”

Source location

2014-0553-Response-by-Care-Uk
Page 2 · response
Published 23 December 2014

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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