PFD report

ETHELINE DE-GALE · Prevention of Future Deaths report

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Issued 16 Feb 2017•Bedfordshire and Luton

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
3

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. Lack of sufficiently specific care plans for required assistance
    Part of recurring concern: Unreliable care-planning processes
  2. Failure to provide guidance for undertaking risk assessments
    Part of recurring concern: Unreliable guidance and communication for safety risk assessments
  3. Insufficient staffing capacity for assisting residents requiring two carers
    Part of recurring concern: Insufficient care-home staffing capacity for residents’ required care
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.1

  1. Action

    Update care plans to require that residents using bedrails are not left unattended when rails are lowered for assistance.

    Stated by Ambassador HouseStated plannedThe respondent said that this action was planned when they made their response on 6 March 2017.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Policies and procedures were followed; the incident resulted from a senior staff member’s negligence.

    Stated by Ambassador HouseDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Lack of sufficiently specific care plans for required assistance

Wider context from the report

“(1) The care plan was too vague to be of assistance to the carers. The carer understood that the deceased required 2 carers to assist her to the commode, but interpreted that as being limited to walking across the floor, but not sitting up in bed with the sides removed or sitting on the side of the bed. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning 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 provide guidance for undertaking risk assessments

Wider context from the report

“(2) The Deputy Manager indicated that the carer should have undertaken a risk assessment, but could offer no guidance on how that was to be achieved. ”

Is this part of a recurring concern?

Yes — Unreliable guidance and communication for safety risk assessments.

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

Insufficient staffing capacity for assisting residents requiring two carers

Wider context from the report

“(3) There were only 2 members of staff on duty, which compromised the safety of other residents when a resident required 2 members of staff to assist. ”

Is this part of a recurring concern?

Yes — Insufficient care-home staffing capacity for residents’ required care.

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

Insufficient staffing capacity for best-interests decisions and hospital accompaniment

Wider context from the report

“(4) There were only 2 members of staff on duty, which potentially could compromise decisions made in the best interests of a resident. One carer accompanying a resident to hospital would clearly create a problem and that could potentially be seen as a basis for not admitting a resident to hospital. ”

Is this part of a recurring concern?

Yes — Insufficient care-home staffing capacity for residents’ required care; Unreliable best-interests decision-making 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 follow paramedics' recommendations

Wider context from the report

“(5) The recommendation of the paramedics appears to have been ignored. ”

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

Update care plans to require that residents using bedrails are not left unattended when rails are lowered for assistance.

Verbatim wording from the response

“The care plan should stipulate that when bedrails are used for any resident and they are lowered for assistance to the resident, the resident must not be left unattended. This will be in place by 3rd March 2017.”

Source location

2017-0058-Response-Ambassador-House-Home
Page 3 · response
Published 6 March 2017

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

Policies and procedures were followed; the incident resulted from a senior staff member’s negligence.

Verbatim wording from the response

“Based on the information from statements, staff interview, care plans, risk assessments and LR’s personnel file, we have concluded that in this case we have acted in accordance with our policies and procedures. The incident occurred, we believe, because of the negligence of a senior staff member (LR).”

Source location

2017-0058-Response-Ambassador-House-Home
Page 3 · response
Published 6 March 2017

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

Seeking specialist treatment rather than a GP was considered justified by the resident’s swollen, painful knee.

Verbatim wording from the response

“The advice of the paramedics to call her GP was ignored on the basis that EDG’s right knee was swollen and painful and therefore the need for a GP to come to the home and instruct us to call an ambulance was negated. It was clear to the Deputy that more specialist treatment was required.”

Source location

2017-0058-Response-Ambassador-House-Home
Page 2 · response
Published 6 March 2017

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

Staffing levels complied with regulations and did not make hospital admission inappropriate.

Verbatim wording from the response

“The numbers of staff on duty at the time of the incident were in line with regulation and are allocated based on need of our residents. At night time the residents are in bed and mostly sleep. There is a requirement of staff to regularly check those residents who require care and to attend residents when they call for assistance. It would be rare for two residents to call at the same time, however, should this be the case, a staff member would attend each resident independently, assess the need for the call, ensure the resident was safe and then prioritise the tasks with their colleague in order to assist the residents. The duty of the care staff attending a resident is to acknowledge the individual risk. In this case LR willingly left EDG on the side of the bed, without thought of her falling.”

Source location

2017-0058-Response-Ambassador-House-Home
Page 2 · response
Published 6 March 2017

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.2

  1. 1

    Invite residents’ relatives to a local solicitor’s presentation explaining lasting powers of attorney for health and welfare and decision-making authority.

    Stated by Ambassador HouseStated plannedThe respondent said that this action was planned when they made their response on 6 March 2017.
  2. 2

    Instruct staff to carry gloves in their pockets so they do not leave residents unattended while providing care.

    Stated by Ambassador HouseStated completedThe respondent said that this action was complete when they made their response on 6 March 2017.

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

Invite residents’ relatives to a local solicitor’s presentation explaining lasting powers of attorney for health and welfare and decision-making authority.

Verbatim wording from the response

“Paramedics who spoke to the Granddaughter, did not ask whether she held a lasting power of attorney for Health and Welfare, in order to make the decision of whether EDG went to hospital during the night or not. We are unsure of whether the paramedic made the decision not to take EDG to hospital on the back of the granddaughters wish or the medical need of EDG. Our learning is to ensure that all residents relatives understand their ability to make decisions on behalf of their relatives, if they do not hold a LPA for health and welfare. We are going to invite our relatives to a presentation from a local solicitor to explain the importance of LPA’s. This will happen by the end of May 2017.”

Source location

2017-0058-Response-Ambassador-House-Home
Page 3 · response
Published 6 March 2017

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

Instruct staff to carry gloves in their pockets so they do not leave residents unattended while providing care.

Verbatim wording from the response

“Staff will be instructed to carry gloves in their pockets at all times, negating the need to leave a resident whilst they are requiring care. This has happened with immediate effect.”

Source location

2017-0058-Response-Ambassador-House-Home
Page 3 · response
Published 6 March 2017

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