PFD report

Hazel Lillian MAYHO · Prevention of Future Deaths report

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Issued 26 Oct 2022•Hampshire, Portsmouth and Southampton

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 effectively observe vulnerable residents entering the garden
    Part of recurring concern: Failure to reliably supervise and monitor residents in care accommodation
  2. Absence of an effective exit control or alert system for residents at risk of entering the garden alone
    Part of recurring concern: Failure to control risks posed by care-home residents to themselves and othersPart of recurring concern: Failure to prevent unsafe unaccompanied exit by vulnerable care-home residents
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

    Install an additional beam to detect garden entry when doors are open.

    Stated by WESTLANDS CARE HOME LTDStated completedThe respondent said that this action was complete when they made their response on 28 October 2022.

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 effectively observe vulnerable residents entering the garden

Wider context from the report

“The deceased was 82 years of age, was severely frail and suffered from dementia. The deceased was assessed as being at high risk of falls and a reputation for wandering around the establishment. The deceased was not unique amongst the other residents in having such vulnerabilities. The lounge areas of the nursing home have doors leading to the garden. The garden has within it potential hazards to a vulnerable resident with a high risk of falls. The doors are kept wide open in warm weather. Whether a resident has entered the garden is only known if they are observed by a member of staff to do so. Members of staff are frequently distracted by other duties hindering their ability to fully and effectively observe vulnerable residents entering the garden. There is an absence of an effective exit control process to ensure that those with a recognised risk of entering the garden alone are prevented from doing so or an effective alert system is triggered when they do so. ”

Is this part of a recurring concern?

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

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

Absence of an effective exit control or alert system for residents at risk of entering the garden alone

Wider context from the report

“The deceased was 82 years of age, was severely frail and suffered from dementia. The deceased was assessed as being at high risk of falls and a reputation for wandering around the establishment. The deceased was not unique amongst the other residents in having such vulnerabilities. The lounge areas of the nursing home have doors leading to the garden. The garden has within it potential hazards to a vulnerable resident with a high risk of falls. The doors are kept wide open in warm weather. Whether a resident has entered the garden is only known if they are observed by a member of staff to do so. Members of staff are frequently distracted by other duties hindering their ability to fully and effectively observe vulnerable residents entering the garden. There is an absence of an effective exit control process to ensure that those with a recognised risk of entering the garden alone are prevented from doing so or an effective alert system is triggered when they do so. ”

Is this part of a recurring concern?

Yes — Failure to control risks posed by care-home residents to themselves and others; Failure to prevent unsafe unaccompanied exit by vulnerable care-home residents.

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

Install an additional beam to detect garden entry when doors are open.

Verbatim wording from the response

“An additional beam has been installed (8th December 2022) – this allows the doors to be open when required in hot weather at residents’ request but it now allows for staff to know if someone has entered into the garden without them being observed should they be busy and not able to see if this has happened as mentioned in your report, this is a separate beam to the door opening and closing.”

Source location

Response from Westlands Care Home
Page 1 · response
Published 28 October 2022

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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