PFD report

Dorothy Ann SPIBY · Prevention of Future Deaths report

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Issued 22 Feb 2022•Birmingham and Solihull

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
5

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
15

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 raised5

  1. Failure to record incidents in nursing records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
  2. Failure to complete incident forms
    Part of recurring concern: Failure to reliably follow up accident reports to prevent recurrencePart of recurring concern: Unreliable reporting of patient-safety incidents
  3. Failure to learn from incidents to safeguard 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.11

  1. Action

    Monitor documentation daily through management checks, record triangulation, spot checks and immediate corrective supervision where shortcomings are identified.

    Stated by PrimeLife LimitedStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2022.
  2. Action

    Develop and disseminate a policy for investigating poor care practice and safeguarding incidents, including statement-taking and evidence correlation.

    Stated by PrimeLife LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 February 2022.
  3. Action

    Complete monthly incident and safeguarding learning reviews and audits, record lessons in action plans, and report themes through regional governance and board risk monitoring.

    Stated by PrimeLife LimitedStated in progressThe respondent said that this action was in progress when they made their response on 24 February 2022.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    Training for the clinical lead cannot currently be completed because the clinical lead is on long-term sick leave.

    Stated by PrimeLife LimitedUnable to actThe respondent said that a constraint prevented them from taking the relevant 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 record incidents in nursing records

Wider context from the report

“1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records. 2. No incident form was completed. 3. No investigation of the accident or the circumstances giving rise to it was undertaken. 4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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 complete incident forms

Wider context from the report

“1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records. 2. No incident form was completed. 3. No investigation of the accident or the circumstances giving rise to it was undertaken. 4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future. ”

Is this part of a recurring concern?

Yes — Failure to reliably follow up accident reports to prevent recurrence; Unreliable reporting of patient-safety incidents.

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 learn from incidents to safeguard residents

Wider context from the report

“1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records. 2. No incident form was completed. 3. No investigation of the accident or the circumstances giving rise to it was undertaken. 4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 investigate accidents and their circumstances

Wider context from the report

“1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records. 2. No incident form was completed. 3. No investigation of the accident or the circumstances giving rise to it was undertaken. 4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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 establish the origin of incident accounts

Wider context from the report

“1. Tamworth Court Nursing Home staff reported to the hospital that Mrs Spiby became distressed and ran into collision with a wall when trying to leave her room, before falling to the floor. The origin of this account was unclear from the evidence. No record was made of the incident in the nursing records. 2. No incident form was completed. 3. No investigation of the accident or the circumstances giving rise to it was undertaken. 4. There was no evidence of a commitment to learning from this incident with a view to safeguarding residents in the future. ”

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

Monitor documentation daily through management checks, record triangulation, spot checks and immediate corrective supervision where shortcomings are identified.

Verbatim wording from the response

“• Any shortcomings in documentation are addressed immediately by the home management team. Conversations with staff are formally recorded within supervisions and any disciplinary action taken, as necessary. Where there is non-compliance found the staff members will be given supervisions and learning sheets will be completed with them to encourage adherence to best practice. Actions in this regard were completed by 18.3.22 as planned.”

Source location

Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022

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

Develop and disseminate a policy for investigating poor care practice and safeguarding incidents, including statement-taking and evidence correlation.

Verbatim wording from the response

“• New policy to be devised about how to conduct an effective investigation into poor care practice and any safeguarding incidents. Must be able to demonstrate how to conduct investigations, how to take statements, how to correlate with documentation etc. Following discussion at recent operational board meeting, this policy will be in situ and disseminated to all Prime Life sites by 30.04.22.”

Source location

Response from Prime Life Ltd
Page 3 · response
Published 24 February 2022

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

Complete monthly incident and safeguarding learning reviews and audits, record lessons in action plans, and report themes through regional governance and board risk monitoring.

Verbatim wording from the response

“• Learning and practice reviews after incidents / safeguarding concerns have been completed and can be evidenced. Incident and safeguarding audits to include an action plan of any lessons learned and a clear plan of how learning and practice can be improved. These reviews will be undertaken each month by the home manager with close monitoring and”

Source location

Response from Prime Life Ltd
Page 3 · response
Published 24 February 2022

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

Conduct daily senior-management incident spot checks, with enhanced governance oversight and escalation of incidents requiring investigation.

Verbatim wording from the response

“• Senior management undertake daily spot checks to ensure that any incidents are identified, and any subsequent actions are noted and addressed. This is overseen by the regional operational team and home management team. The associate director for elderly services is currently supporting the home 3-4 days per week and is responsible for ensuring governance in this area. Daily spot checks commenced on 18.3.22 and continued oversight and monitoring needed in the future. Monitoring of the documentation will be undertaken at the commencement of the day shift (around 8am) and at around 4pm with regular spot checks also being undertaken during the day. This process of monitoring will continue long term and become part of each day’s routine activities.”

Source location

Response from Prime Life Ltd
Page 3 · response
Published 24 February 2022

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

Ensure nursing and care staff read and understand accident, incident and falls-management policies.

Verbatim wording from the response

“• All nursing and care staff to be aware of Prime Life Accident/Incident Policies and Management of Falls Policy- evidence to be left staff have read and understand these policies. Actions to be completed by 11.4.22 and timeframes met.”

Source location

Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022

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

Deliver safeguarding training covering reportable incidents, incident reporting and incident auditing, with regional oversight of timely external reporting.

Verbatim wording from the response

“• Safeguarding training has been delivered by the internal quality team, this included reportable incidents, incident reports and auditing of incidents. It is now the responsibility of the regional operations team to ensure that any reportable incidents are being sent through to the local authority and other interested parties without delay. The manager’s review of incident reports will be completed and overseen by the regional operational team. Training to be delivered by the providers Quality Matters Team. This initial action was completed by 25.3.22.”

Source location

Response from Prime Life Ltd
Page 3 · response
Published 24 February 2022

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

Deliver falls-management and head-injury training to nurses, covering observations, documentation, assessments, care planning and falls-risk reduction.

Verbatim wording from the response

“• Falls Management including Head Injury Training for all nurses. Training to be delivered by the nurse trainer/advisor and to include: Body Mapping, vital observations including Neuro-observations, RESTORE2(NEWS2), Accident/Incident forms, care plans, risk assessments, daily notes, communication record – MDT and reducing the risk of falls. Actions to be completed by 22.4.22 (slight amendment to the original action plan in place due to annual leave and sickness amongst the nursing team) with the exception of the clinical lead who is currently on long term sick.”

Source location

Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022

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

Conduct regular competency checks to confirm staff retain documentation training and demonstrate good practice.

Verbatim wording from the response

“• Further competency checks are being conducted to ensure continued learning. This will be completed by the nurse advisor/trainer on a regular basis (weekly at present) and will cover a period of 3 months or longer if issues arise from the competency checks. Competency checks will only be ceased if the advisor/trainer is confident that the information has been retained and good practice demonstrated.”

Source location

Response from Prime Life Ltd
Page 1 · response
Published 24 February 2022

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

Complete documentation and record-keeping training for nursing and care staff, including policy reissue and good-practice requirements.

Verbatim wording from the response

“• Defensible Documentation Training for Registered Nurses initiated by Nurse Advisor ████████ ████████. Training included: NMC Code, Accountability, Effective communication, Examples of good and poor documentation, NMC Hearings and clinical negligence. Training was planned in to be completed by 15.4.22 and actions have been completed with all Tanworth Court nurses.”

Source location

Response from Prime Life Ltd
Page 1 · response
Published 24 February 2022

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

Send a lessons-learned document monthly to every Prime Life location, sharing good and poor practice and resulting procedural improvements.

Verbatim wording from the response

“• A new lessons learned document will be sent to each Prime Life location every month to share both good and bad practice. This will encompass any new documentation/procedure put into place as the result of internal reviews of practice across the group. This will be completed each month by ████████, lead operational director, to commence 1 May 2022 and monthly thereafter.”

Source location

Response from Prime Life Ltd
Page 4 · response
Published 24 February 2022

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

Provide nurses with incident-form completion training and supervision, including body mapping.

Verbatim wording from the response

“• Nurses to have training/supervision in Incident Form completion including body mapping. Training and supervisions to be undertaken by nurse trainer/advisor and timeframes set to 15.4.22. This has been completed by all nurses with the exception of the clinical lead who is”

Source location

Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022

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

Training for the clinical lead cannot currently be completed because the clinical lead is on long-term sick leave.

Verbatim wording from the response

“• Falls Management including Head Injury Training for all nurses. Training to be delivered by the nurse trainer/advisor and to include: Body Mapping, vital observations including Neuro-observations, RESTORE2(NEWS2), Accident/Incident forms, care plans, risk assessments, daily notes, communication record – MDT and reducing the risk of falls. Actions to be completed by 22.4.22 (slight amendment to the original action plan in place due to annual leave and sickness amongst the nursing team) with the exception of the clinical lead who is currently on long term sick.”

Source location

Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022

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

Incident investigations are undertaken only when the home's practice meets the threshold warranting investigation, with enhanced monitoring supporting escalation when necessary.

Verbatim wording from the response

“• Senior management undertake daily spot checks to ensure that any incidents are identified, and any subsequent actions are noted and addressed. This is overseen by the regional operational team and home management team. The associate director for elderly services is currently supporting the home 3-4 days per week and is responsible for ensuring governance in this area. Daily spot checks commenced on 18.3.22 and continued oversight and monitoring needed in the future. Monitoring of the documentation will be undertaken at the commencement of the day shift (around 8am) and at around 4pm with regular spot checks also being undertaken during the day. This process of monitoring will continue long term and become part of each day’s routine activities.”

Source location

Response from Prime Life Ltd
Page 3 · response
Published 24 February 2022

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.4

  1. 1

    Train senior management on responsibilities and procedures for investigating staff conduct, poor competency and non-compliance fairly and effectively.

    Stated by PrimeLife LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 February 2022.
  2. 2

    Deliver falls-prevention training to care staff on identifying and reducing risks and supporting residents after falls.

    Stated by PrimeLife LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 February 2022.
  3. 3

    Train care staff to complete ABC charts, assess situations and share relevant information with nurses and senior management.

    Stated by PrimeLife LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 February 2022.
  4. 4

    Complete outstanding clinical-lead training on falls, incident documentation and ABC-chart procedures when the clinical lead returns.

    Stated by PrimeLife LimitedStated plannedThe respondent said that this action was planned when they made their response on 24 February 2022.

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

Train senior management on responsibilities and procedures for investigating staff conduct, poor competency and non-compliance fairly and effectively.

Verbatim wording from the response

“• Human Resources team to undertake training with senior management to ensure they are aware of their responsibilities with regards to investigations into staff conduct, how to demonstrate equality and fairness to employees, how to reach resolution into inappropriate conduct/competency, the options available for formal action for continued non-compliance etc. Was originally expected to have been completed by 15.4.22 but due to unforeseen circumstances, this timeframe has not been met but will be completed by 22.4.22”

Source location

Response from Prime Life Ltd
Page 3 · response
Published 24 February 2022

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

Deliver falls-prevention training to care staff on identifying and reducing risks and supporting residents after falls.

Verbatim wording from the response

“• Falls prevention training to be given to all care staff to aid identifying risks associated with falls, how to minimize the risk of falls and how to support the clients involved in such incidents. Training to be completed by all care staff by 22.4.22 (slight amendment to the original action plan in place due to annual leave and sickness amongst the nursing team), with the exception of the clinical lead who is currently on long term sick.”

Source location

Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022

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

Train care staff to complete ABC charts, assess situations and share relevant information with nurses and senior management.

Verbatim wording from the response

“• Training to be completed with all care staff on how to effectively complete an ABC chart, appropriate assessment of the situation and how to share the information with nurses and senior management. Training to be completed by all nurses by 22.4.22 with the exception of the clinical lead who is currently on long term sick.”

Source location

Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022

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

Complete outstanding clinical-lead training on falls, incident documentation and ABC-chart procedures when the clinical lead returns.

Verbatim wording from the response

“• Upon the clinical lead’s return we will prioritise the training required for the clinical lead to be completed.”

Source location

Response from Prime Life Ltd
Page 2 · response
Published 24 February 2022

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