PFD report

Beryl Ann Walsh · Prevention of Future Deaths report

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Issued 19 Nov 2018•Manchester North

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
5

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

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 raised5

  1. Failure to refer people at high risk of falls to the falls prevention team
    Part of recurring concern: Inadequate control of falls risks
  2. Failure to undertake falls prevention care plans
    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 processes
  3. Failure to provide falls prevention equipment
    Part of recurring concern: Inadequate control of falls risks
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.4

  1. Action

    Strengthen risk assessments for residents who have experienced falls.

    Stated by Beechwood LodgeStated completedThe respondent said that this action was complete when they made their response on 25 April 2019.
  2. Action

    Implement a falls matrix to monitor falls and support referrals to the falls team when required.

    Stated by Beechwood LodgeStated completedThe respondent said that this action was complete when they made their response on 25 April 2019.
  3. Action

    Add safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.

    Stated by Beechwood LodgeStated completedThe respondent said that this action was complete when they made their response on 25 April 2019.

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

  1. Position

    Falls-prevention equipment was considered inappropriate because of trip hazards from extremely poor eyesight, with the existing call bell enabling assistance when required.

    Stated by Beechwood LodgeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 refer people at high risk of falls to the falls prevention team

Wider context from the report

“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 to undertake falls prevention care plans

Wider context from the report

“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”

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.

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 to provide falls prevention equipment

Wider context from the report

“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 to undertake falls risk assessments

Wider context from the report

“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable completion and verification of falls-risk assessments.

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 to identify people at high risk of falls

Wider context from the report

“1. That there were multiple missed opportunities to identify the deceased as a person of high risk of falls and to escalate her care by way of a referral to the falls team. Furthermore, there were multiple missed opportunities to provide the deceased with falls prevention equipment and to undertake falls risk assessments and care plans. I remain concerned that appropriate action to minimise the risk of deaths occurring in similar circumstances has not been taken by Beechwood Lodge Care Home. During the last 12 months of her life she had fallen on multiple occasions. However, she had not been referred to the falls prevention team and had not been provided with any falls prevention equipment. No care plans and falls risk assessments had been undertaken ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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

Strengthen risk assessments for residents who have experienced falls.

Verbatim wording from the response

“1. We have put more in robust risk assessments for residents who have had falls.”

Source location

2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019

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

Implement a falls matrix to monitor falls and support referrals to the falls team when required.

Verbatim wording from the response

“3. We have now put all new risk assessments in all care plans about safety equipment whether they use it or why they do and the reasons why they don’t. I also have put in place a falls matrix, so I can monitor falls and do referrals to falls team when required.”

Source location

2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019

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 safety-equipment risk assessments to care plans, including whether equipment is used and reasons for non-use.

Verbatim wording from the response

“3. We have now put all new risk assessments in all care plans about safety equipment whether they use it or why they do and the reasons why they don’t. I also have put in place a falls matrix, so I can monitor falls and do referrals to falls team when required.”

Source location

2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019

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

Refer all falls-risk concerns to appropriate professionals, including doctors and falls teams.

Verbatim wording from the response

“4. We will ensure all falls risk concerns are referred to appropriate professionals i.e. doctors and falls teams.”

Source location

2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019

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

Falls-prevention equipment was considered inappropriate because of trip hazards from extremely poor eyesight, with the existing call bell enabling assistance when required.

Verbatim wording from the response

“The falls that BW sustained was over a 3 and half year period, the equipment what would be usually required was more of a risk to BW due to extremely poor eyesight so equipment for falls prevention was not appropriate due to trip hazards, however BW had good capacity so was able to use the call bell she had in place when she required assistance.”

Source location

2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019

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

    Document all conversations with relatives and professionals.

    Stated by Beechwood LodgeStated completedThe respondent said that this action was complete when they made their response on 25 April 2019.

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

Document all conversations with relatives and professionals.

Verbatim wording from the response

“2. We are documenting all conversations with relatives and professionals.”

Source location

2018-0359-Response-by-Beechwood-Lodge
Page 1 · response
Published 25 April 2019

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