PFD report

PAULINE VIOLET OAKLEY · Prevention of Future Deaths report

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Issued 18 Sep 2020•Inner North London

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
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
7

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 raised3

  1. Failure to provide monitoring of the fire alarm in the flats
    Part of recurring concern: Failure of fire detection systems to reliably alert and trigger emergency response
  2. Failure to assess the safety or suitability of the home and appliances as part of hospital discharge planning
    Part of recurring concern: Unreliable hospital discharge processes
  3. Failure to assess the safety or suitability of the home and appliances as part of the Co-ordinate My Care Plan
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.2

  1. Action

    Ensure the multidisciplinary team and Social Services are informed when concerns about a vulnerable patient’s home safety are raised or suspected.

    Stated by Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
  2. Action

    Prompt the Care Navigator or Social Worker at monthly multidisciplinary meetings to ensure appropriate fire-safety checks are implemented.

    Stated by Recipient name withheldStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    Responsibility for environmental risk assessments after discharge lay with the Reablement Team within the London Borough of Tower Hamlets.

    Stated by East London NHS Foundation TrustRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 monitoring of the fire alarm in the flats

Wider context from the report

“(3) The fire alarm in the flats was apparently not monitored by East End Homes, the police or the London Fire Brigade. When an alarm was activated it was dependent upon a resident in the flats or a member of the public to call the emergency services. Residents in the flats may have thought that the alarm was monitored and therefore there was no need for any resident to call the emergency services. ”

Is this part of a recurring concern?

Yes — Failure of fire detection systems to reliably alert and trigger emergency 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 the safety or suitability of the home and appliances as part of hospital discharge planning

Wider context from the report

“(1) There was no assessment of the safety or suitability of Pauline Oakley’s flat, or the appliances within the flat arranged by the NHS Trust Foundation responsible for her discharge home as part of the hospital discharge plan. The evidence was that she had fallen on a modern electric heater, with a built in safety mechanism, there would have been no fire. ”

Is this part of a recurring concern?

Yes — Unreliable hospital discharge 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 assess the safety or suitability of the home and appliances as part of the Co-ordinate My Care Plan

Wider context from the report

“(2) There was no assessment of the safety or suitability of Pauline Oakley’s flat, or the appliances within the flat arranged by as part of the Co-ordinate My Care Plan. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 the multidisciplinary team and Social Services are informed when concerns about a vulnerable patient’s home safety are raised or suspected.

Verbatim wording from the response

“I have discussed this tragic case with the practice clinical team. We all have a duty of care with respect to adult safeguarding when caring for vulnerable patients. In this regard, we are responsible for raising concerns about the adequacy or safety of the home environment to the relevant authorities. Whilst no such concerns were raised with us in this case, the GP practice team has agreed that, in cases like this, where a concern is raised or suspected we will ensure the multi-disciplinary team and Social Services are made aware, especially if they have specific (and relevant) areas of responsibility, such as fire safety risk assessments.”

Source location

2020-0304-Response-from-GP-Redacted
Page 4 · response
Published 14 January 2021

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

Prompt the Care Navigator or Social Worker at monthly multidisciplinary meetings to ensure appropriate fire-safety checks are implemented.

Verbatim wording from the response

“The practice has a longstanding monthly Integrated Care Multidisciplinary Team Meeting which is attended by the Practice GPs, the extended primary care team, the social worker and the palliative care team. We reviewed our practise with regard to concerns about fire safety at the Integrated Care Meeting which immediately followed the Inquest and again at the weekly Practice Meeting on Friday 29th January 2021. It was agreed that Clinicians could prompt the Care Navigator or the Social”

Source location

2020-0304-Response-from-GP-Redacted
Page 4 · response
Published 14 January 2021

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

Responsibility for environmental risk assessments after discharge lay with the Reablement Team within the London Borough of Tower Hamlets.

Verbatim wording from the response

“████████, Legal Affairs Manager was present at the Inquest and informed you that it was her understanding that responsibility for environmental risk assessment following Ms Oakley’s discharge from hospital, would lie with the Reablement Team. The Reablement Team falls within the remit of the London Borough of Tower Hamlets. The Trust understands that the Reablement Team were providing Ms Oakley with regular support following her discharge in order to help her with everyday tasks and ensure that she could live as independently as possible.”

Source location

2020-0304-Response-from-East-London-NHS-Foundation-Trust_Redacted
Page 1 · response
Published 14 January 2021

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

Occupational therapy assesses functional safety in the home but does not assess the safety or adequacy of electrical appliances.

Verbatim wording from the response

“To the best of my knowledge and belief, an Occupational Therapy assessment is a functional assessment (looking, for example, at the need for hand rails or ramps, or having tools in place to help the patient function better or more safely in the home environment). It would not go as far as to assess the safety of electrical appliances, such as the age or adequacy of the electrical heater in this case. Whilst it is correct to say an Occupational Therapy assessment can be initiated by the GP, Mrs Oakley was returning to an integrated, multi-disciplinary umbrella of care, including the Occupational Therapy Reablement Team provided by Tower Hamlets Local Authority/Social Services. Therefore in this scenario there was no further need for a GP referral for an Occupational Therapy assessment to be made as this was already in place.”

Source location

2020-0304-Response-from-GP-Redacted
Page 4 · response
Published 14 January 2021

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

No further GP occupational therapy referral was needed because the patient was already under an integrated care arrangement including the local-authority reablement team.

Verbatim wording from the response

“To the best of my knowledge and belief, an Occupational Therapy assessment is a functional assessment (looking, for example, at the need for hand rails or ramps, or having tools in place to help the patient function better or more safely in the home environment). It would not go as far as to assess the safety of electrical appliances, such as the age or adequacy of the electrical heater in this case. Whilst it is correct to say an Occupational Therapy assessment can be initiated by the GP, Mrs Oakley was returning to an integrated, multi-disciplinary umbrella of care, including the Occupational Therapy Reablement Team provided by Tower Hamlets Local Authority/Social Services. Therefore in this scenario there was no further need for a GP referral for an Occupational Therapy assessment to be made as this was already in place.”

Source location

2020-0304-Response-from-GP-Redacted
Page 4 · response
Published 14 January 2021

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

Hospital discharge planning, including functional assessment before discharge, is the hospital team’s responsibility; primary care is not involved.

Verbatim wording from the response

“In respect of The Royal London Hospital (Barts Health NHS Trust), where Ms Oakley was admitted and discharged, it is usual practice for a patient to be deemed fit from both a medical and social/functional perspective before they are discharged home (the Coroner will no-doubt hear from the relevant Trust in this regard). This would be part of the assessment by the hospital medical team and by a hospital Multi-Disciplinary Team consisting, more likely than not, of an Occupational Therapist, Physiotherapist and Social Worker in order to prepare a hospital discharge plan. The GP (Primary Care Provider) is not involved in hospital discharge planning. However, we would normally receive a discharge summary from the hospital with a brief medical summary, information about medication on discharge, and any medical follow up required.”

Source location

2020-0304-Response-from-GP-Redacted
Page 3 · response
Published 14 January 2021

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

The Coordinate My Care Plan is limited to communicating clinical information and does not assess home or appliance safety.

Verbatim wording from the response

“In respect of the Co-ordinate My Care Plan, I went on to say:”

Source location

2020-0304-Response-from-GP-Redacted
Page 3 · response
Published 14 January 2021

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.5

  1. 1

    Continue routinely highlighting the Fire Safety leaflet and other important leaflets through resident newsletters and the website.

    Stated by EastendHomesStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  2. 2

    Discuss lessons from the case with district nursing staff during regular team meetings.

    Stated by East London NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
  3. 3

    Attend an adult safeguarding webinar covering hoarding and fire safety responsibilities.

    Stated by Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  4. 4

    Discuss adult safeguarding responsibilities and home-environment safety concerns with the practice clinical team.

    Stated by Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  5. 5

    Review practice arrangements for addressing fire-safety concerns at integrated-care and practice meetings.

    Stated by Recipient name withheldStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.3

  1. 1

    Domestic smoke alarms were considered appropriate, properly maintained and effective, with resident guidance sufficient to require no additional fire-alarm management action.

    Stated by EastendHomesExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.
  2. 2

    Environmental risk assessments were outside the district nursing team’s scope, which was limited to wound care and clinical issues.

    Stated by East London NHS Foundation TrustOutside remitThe respondent said that this matter was outside its role or authority.
  3. 3

    Social Services is the lead agency responsible for health and safety in the home environment, including fire safety checks.

    Stated by Recipient name withheldRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Continue routinely highlighting the Fire Safety leaflet and other important leaflets through resident newsletters and the website.

Verbatim wording from the response

“In conclusion, we have carefully considered the concerns detailed in the report and believe the smoke alarms were of an appropriate standard, had been properly installed and maintained and had operated when activated. We are also of the view that EeH provides guidance on the action to take when a domestic smoke alarm continues longer than normal. EastendHomes periodically draws attention to the Fire Safety leaflet and other important leaflets in our resident newsletter and web site and this is undertaken on a routine basis.”

Source location

2020-0304-Response-from-East-End-Homes_Redacted
Page 2 · response
Published 14 January 2021

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

Discuss lessons from the case with district nursing staff during regular team meetings.

Verbatim wording from the response

“To conclude, whilst responsibility for the environmental risk assessment lay outside the responsibility of the district nursing team, to ensure that lessons can be learned from this tragic case, it will be the subject of discussion with staff within their regular team meetings.”

Source location

2020-0304-Response-from-East-London-NHS-Foundation-Trust_Redacted
Page 2 · response
Published 14 January 2021

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

Attend an adult safeguarding webinar covering hoarding and fire safety responsibilities.

Verbatim wording from the response

“Since the Inquest, I have attended an Adult Safeguarding webinar (Hoarding and Fire Safety) for Waltham Forest East London CCGs (WEL). At the webinar, I asked who was responsible for ensuring a fire safety check was administered. The response was that Social Services is the lead agency for Health and Safety in the home environment and that, therefore, if Social Services is involved in the patient’s care it is their responsibility.”

Source location

2020-0304-Response-from-GP-Redacted
Page 4 · response
Published 14 January 2021

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

Discuss adult safeguarding responsibilities and home-environment safety concerns with the practice clinical team.

Verbatim wording from the response

“I have discussed this tragic case with the practice clinical team. We all have a duty of care with respect to adult safeguarding when caring for vulnerable patients. In this regard, we are responsible for raising concerns about the adequacy or safety of the home environment to the relevant authorities. Whilst no such concerns were raised with us in this case, the GP practice team has agreed that, in cases like this, where a concern is raised or suspected we will ensure the multi-disciplinary team and Social Services are made aware, especially if they have specific (and relevant) areas of responsibility, such as fire safety risk assessments.”

Source location

2020-0304-Response-from-GP-Redacted
Page 4 · response
Published 14 January 2021

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

Review practice arrangements for addressing fire-safety concerns at integrated-care and practice meetings.

Verbatim wording from the response

“The practice has a longstanding monthly Integrated Care Multidisciplinary Team Meeting which is attended by the Practice GPs, the extended primary care team, the social worker and the palliative care team. We reviewed our practise with regard to concerns about fire safety at the Integrated Care Meeting which immediately followed the Inquest and again at the weekly Practice Meeting on Friday 29th January 2021. It was agreed that Clinicians could prompt the Care Navigator or the Social”

Source location

2020-0304-Response-from-GP-Redacted
Page 4 · response
Published 14 January 2021

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

Domestic smoke alarms were considered appropriate, properly maintained and effective, with resident guidance sufficient to require no additional fire-alarm management action.

Verbatim wording from the response

“In conclusion, we have carefully considered the concerns detailed in the report and believe the smoke alarms were of an appropriate standard, had been properly installed and maintained and had operated when activated. We are also of the view that EeH provides guidance on the action to take when a domestic smoke alarm continues longer than normal. EastendHomes periodically draws attention to the Fire Safety leaflet and other important leaflets in our resident newsletter and web site and this is undertaken on a routine basis.”

Source location

2020-0304-Response-from-East-End-Homes_Redacted
Page 2 · response
Published 14 January 2021

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

Environmental risk assessments were outside the district nursing team’s scope, which was limited to wound care and clinical issues.

Verbatim wording from the response

“Our Lead Nurse for community nursing in Tower Hamlets has confirmed that it would not be part of the scope of the district nursing team to undertake an environmental risk assessment. Their role in Ms Oakley’s case was to provide wound care and to manage any clinical issues arising. Having said that should any of the nurses have observed anything that posed an obvious health and safety risk, that would have been addressed. However, you will be aware from Nurse ████████’s evidence at the Inquest, that she did not identify any such concerns and specifically she did not see an electric heater when she visited Ms Oakley.”

Source location

2020-0304-Response-from-East-London-NHS-Foundation-Trust_Redacted
Page 1 · response
Published 14 January 2021

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

Social Services is the lead agency responsible for health and safety in the home environment, including fire safety checks.

Verbatim wording from the response

“Since the Inquest, I have attended an Adult Safeguarding webinar (Hoarding and Fire Safety) for Waltham Forest East London CCGs (WEL). At the webinar, I asked who was responsible for ensuring a fire safety check was administered. The response was that Social Services is the lead agency for Health and Safety in the home environment and that, therefore, if Social Services is involved in the patient’s care it is their responsibility.”

Source location

2020-0304-Response-from-GP-Redacted
Page 4 · response
Published 14 January 2021

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