PFD report

Robert Edward LOWE · Prevention of Future Deaths report

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Issued 20 Sep 2019•County Durham and Darlington

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
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.

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Concerns and recipient responses

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Concerns raised2

  1. Failure of pressure mats to prevent residents bypassing bed-exit detection
    Part of recurring concern: Failure to reliably supervise and monitor residents in care accommodation
  2. Failure of audible alarm signals to come to staff attention
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 of pressure mats to prevent residents bypassing bed-exit detection

Wider context from the report

“A) Circumstances at Chilton Care Centre are such that the placing of pressure mats (intended to detect residents leaving their beds unaided) is such that residents may bypass those mats; B) The use and operation of audible signals is such that important audible alarms may not come to the attention of staff. Mr LOWE left his bed and fell unwitnessed and then lay undetected by his bed for up to two hours until a scheduled welfare check. The pressure mat may not have been triggered. The basis for my concern is as follows: (A) ████████, Chilton Home Manager said that when she investigated this matter (by which time the mat had been removed) "...there could have been a possibility that Mr LOWE, may have bypassed the mat when getting out at the top of his bed..."(witness statement dated 11th August 2019); and (B) In the same statement, ████████ stated: "Then... when staff carried out another welfare check, they found Mr Lowe on the floor. Three out of 4 staff on duty and only one believes that the mat had not activated and the other 3 could not remember if the sensor mat was making a sound or not, as the emergency buzzer was pressed and other buzzers around the home were also going at the same time, and their priority was Mr Lowe..." ”

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 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 of audible alarm signals to come to staff attention

Wider context from the report

“A) Circumstances at Chilton Care Centre are such that the placing of pressure mats (intended to detect residents leaving their beds unaided) is such that residents may bypass those mats; B) The use and operation of audible signals is such that important audible alarms may not come to the attention of staff. Mr LOWE left his bed and fell unwitnessed and then lay undetected by his bed for up to two hours until a scheduled welfare check. The pressure mat may not have been triggered. The basis for my concern is as follows: (A) ████████, Chilton Home Manager said that when she investigated this matter (by which time the mat had been removed) "...there could have been a possibility that Mr LOWE, may have bypassed the mat when getting out at the top of his bed..."(witness statement dated 11th August 2019); and (B) In the same statement, ████████ stated: "Then... when staff carried out another welfare check, they found Mr Lowe on the floor. Three out of 4 staff on duty and only one believes that the mat had not activated and the other 3 could not remember if the sensor mat was making a sound or not, as the emergency buzzer was pressed and other buzzers around the home were also going at the same time, and their priority was Mr Lowe..." ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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