PFD report

Catherine Jux · Prevention of Future Deaths report

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Issued 2 Jun 2021•Mid Kent and Medway

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
3

Raised in this report

Recipients
2

Named on the report

Responses found
0

Of 2 recipients

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

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

Concerns raised3

  1. Failure to complete risk assessments within 24 hours of admission
    Part of recurring concern: Unreliable admission assessment of patientsPart of recurring concern: Unreliable completion of admission documentationPart of recurring concern: Unreliable safety assessment of new care-home residents on admission
  2. Failure of care staff to notice missing risk assessments when assessing patients’ daily needs and requirements
    Part of recurring concern: Unreliable patient risk-assessment processes
  3. Inadequate auditing of assessment completion
    Part of recurring concern: Failure of care and safety auditing to identify deficienciesPart of recurring concern: Unreliable patient risk-assessment processes
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 complete risk assessments within 24 hours of admission

Wider context from the report

“Evidence was given by Nursing Home manager and Nursing staff at the Elvy Court Nursing Home that: (1) Due to an oversight by the home a risk assessment was not completed within 24 hours of the patient being admitted to the home. (2) None of the Care Home staff who attended to the patient and who would refer to this risk assessment to assess a patient’s daily needs and requirements noticed the oversight in respect of this. (3) There is not an adequate process in place for auditing that assessments have been completed particularly given the homes policy that they are completed within 24 hours of admission. ”

Is this part of a recurring concern?

Yes — Unreliable admission assessment of patients; Unreliable completion of admission documentation; Unreliable safety assessment of new care-home residents on admission.

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 of care staff to notice missing risk assessments when assessing patients’ daily needs and requirements

Wider context from the report

“Evidence was given by Nursing Home manager and Nursing staff at the Elvy Court Nursing Home that: (1) Due to an oversight by the home a risk assessment was not completed within 24 hours of the patient being admitted to the home. (2) None of the Care Home staff who attended to the patient and who would refer to this risk assessment to assess a patient’s daily needs and requirements noticed the oversight in respect of this. (3) There is not an adequate process in place for auditing that assessments have been completed particularly given the homes policy that they are completed within 24 hours of admission. ”

Is this part of a recurring concern?

Yes — Unreliable patient risk-assessment 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

Inadequate auditing of assessment completion

Wider context from the report

“Evidence was given by Nursing Home manager and Nursing staff at the Elvy Court Nursing Home that: (1) Due to an oversight by the home a risk assessment was not completed within 24 hours of the patient being admitted to the home. (2) None of the Care Home staff who attended to the patient and who would refer to this risk assessment to assess a patient’s daily needs and requirements noticed the oversight in respect of this. (3) There is not an adequate process in place for auditing that assessments have been completed particularly given the homes policy that they are completed within 24 hours of admission. ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies; Unreliable patient risk-assessment processes.

Open source report
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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