PFD report

Mr Vincent Smith · Prevention of Future Deaths report

Pin Get email alerts Request correction

Issued 6 Apr 2016•Sunderland

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
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

Open published report

Concerns and recipient responses

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

Concerns raised2

  1. Failure to act upon vulnerability after a fall
    Part of recurring concern: Unreliable post-fall assessment and clinical response
  2. Failure to assess vulnerability after a fall
Responses linked to these concerns

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

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 act upon vulnerability after a fall

Wider context from the report

“Whilst at the Village Nursing and Care Home members of staff were to monitor and support Mr Smith’s mobilisation. Although being on notice after his first fall, there were insufficient steps taken to assess and act upon Mr Smith’s vulnerability. Evidence suggested that there ought to be: - 1) a review of the Home’s formal written admissions policy to include verification of the information provided about the suitability of a prospective resident for admission, as well as 2) a review of the Home’s formal written falls risk assessments policy and associated training for staff, together with any other steps that ought to be taken to mitigate the risks of falls. ”

Is this part of a recurring concern?

Yes — Unreliable post-fall assessment and clinical response.

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 assess vulnerability after a fall

Wider context from the report

“Whilst at the Village Nursing and Care Home members of staff were to monitor and support Mr Smith’s mobilisation. Although being on notice after his first fall, there were insufficient steps taken to assess and act upon Mr Smith’s vulnerability. Evidence suggested that there ought to be: - 1) a review of the Home’s formal written admissions policy to include verification of the information provided about the suitability of a prospective resident for admission, as well as 2) a review of the Home’s formal written falls risk assessments policy and associated training for staff, together with any other steps that ought to be taken to mitigate the risks of falls. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report
Back to top

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