PFD report

Diane POOLE · Prevention of Future Deaths report

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Issued 13 Jan 2025•Liverpool and the Wirral

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
9

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 raised2

  1. Faulty emergency exit door
    Part of recurring concern: Unsafe emergency egress arrangements
  2. Lack of staff awareness
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.4

  1. Action

    Use a senior staff messaging group to communicate resident-focused shift handover information to seniors and management.

    Stated by Victoria House (Wallasey) LtdStated completedThe respondent said that this action was complete when they made their response on 15 January 2025.
  2. Action

    Deliver staff training on safeguarding, nutrition and hydration, deprivation of liberty safeguards, communication, reporting, recording, daily tasks and teamwork.

    Stated by Victoria House (Wallasey) LtdStated in progressThe respondent said that this action was in progress when they made their response on 15 January 2025.
  3. Action

    Close the front lounge area containing the escape door to residents and repurpose it as a meeting and family room.

    Stated by Victoria House (Wallasey) LtdStated completedThe respondent said that this action was complete when they made their response on 15 January 2025.

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

Faulty emergency exit door

Wider context from the report

“The Court received evidence of the following: The investigation uncovered both the fault of the emergency exit door and a lack of awareness among the staff, highlighting the need for immediate corrective measures to prevent a recurrence of this incident. To address these issues, several actions will be implemented. Immediate corrective actions have been implemented to prevent a recurrence of this incident. Actions include: I Rigorous Alarm Checks: Regular inspections of all emergency exit alarms to ensure they are functioning correctly. I Increased Resident Headcounts: Staff will conduct hourly headcounts of all residents, with half-hour checks for those deemed high-risk. I Engaging Activities for High-Risk Residents: Structured, stimulating activities will be introduced to engage high-risk residents and reduce behaviours that may lead to attempts to leave the facility. I Improved Shift Handover Procedures: Shift handovers will be more resident-focused, ensuring clear communication and continuity of care. I Ongoing Staff Training: Regular training sessions will be conducted to reinforce the importance of supervision, resident safety, and emergency procedures. The Court seeks clarification that these actions have been implemented and are continuing ”

Is this part of a recurring concern?

Yes — Unsafe emergency egress arrangements.

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

Lack of staff awareness

Wider context from the report

“The Court received evidence of the following: The investigation uncovered both the fault of the emergency exit door and a lack of awareness among the staff, highlighting the need for immediate corrective measures to prevent a recurrence of this incident. To address these issues, several actions will be implemented. Immediate corrective actions have been implemented to prevent a recurrence of this incident. Actions include: I Rigorous Alarm Checks: Regular inspections of all emergency exit alarms to ensure they are functioning correctly. I Increased Resident Headcounts: Staff will conduct hourly headcounts of all residents, with half-hour checks for those deemed high-risk. I Engaging Activities for High-Risk Residents: Structured, stimulating activities will be introduced to engage high-risk residents and reduce behaviours that may lead to attempts to leave the facility. I Improved Shift Handover Procedures: Shift handovers will be more resident-focused, ensuring clear communication and continuity of care. I Ongoing Staff Training: Regular training sessions will be conducted to reinforce the importance of supervision, resident safety, and emergency procedures. The Court seeks clarification that these actions have been implemented and are continuing ”

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

Use a senior staff messaging group to communicate resident-focused shift handover information to seniors and management.

Verbatim wording from the response

“Improved Shift Handover Procedures | Shift handovers will be more resident focused, ensuring clean communication and continuity of care. | Team Leaders and Management | | Already completed | Introduction of senior what’s app group that is shared with all seniors and management at the end of every shift”

Source location

Response from Victoria Residential Home
Page 2 · response
Published 15 January 2025

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 staff training on safeguarding, nutrition and hydration, deprivation of liberty safeguards, communication, reporting, recording, daily tasks and teamwork.

Verbatim wording from the response

“Ongoing Staff Training | Regular training to reinforce the importance of supervision, resident safety and emergency procedures | Management | | March 25 | Staff re-enrolled on Safeguarding training along with Nutrition and Hydration (as it was found that staff did not notice that residents were missing during morning drinks round). Staff also enrolled on DOLS course and a further general role centred course covering the importance of Communication, Reporting and Recording, Daily Tasks and Team Working.”

Source location

Response from Victoria Residential Home
Page 2 · response
Published 15 January 2025

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

Close the front lounge area containing the escape door to residents and repurpose it as a meeting and family room.

Verbatim wording from the response

“Closure of the front lounge area where the escape door is situated | Area closed off following the incident | Management | | 31.08.24 | The lounge area was immediately closed off and is now closed to residents (now being used a meeting room – family room).”

Source location

Response from Victoria Residential Home
Page 3 · response
Published 15 January 2025

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 hourly resident headcounts, with half-hour checks for residents assessed as high risk.

Verbatim wording from the response

“Increased Resident “Headcounts” | Staff will conduct hourly “headcounts” of all residents, with half hour checks for those deemed high risk | Team Leaders | | Already Completed | Introduced immediately following the incident and ongoing daily.”

Source location

Response from Victoria Residential Home
Page 2 · response
Published 15 January 2025

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

    Make the conservatory door permanently inaccessible by changing its hinges and removing its opening mechanism and handle.

    Stated by Victoria House (Wallasey) LtdStated completedThe respondent said that this action was complete when they made their response on 15 January 2025.
  2. 2

    Provide structured daily activities for high-risk residents through an activities coordinator working five afternoons per week.

    Stated by Victoria House (Wallasey) LtdStated completedThe respondent said that this action was complete when they made their response on 15 January 2025.
  3. 3

    Conduct and record emergency exit alarm checks at shift changes and daily management checks.

    Stated by Victoria House (Wallasey) LtdStated completedThe respondent said that this action was complete when they made their response on 15 January 2025.
  4. 4

    Secure the front entrance and foyer access using electronic fobs and a self-closing door.

    Stated by Victoria House (Wallasey) LtdStated completedThe respondent said that this action was complete when they made their response on 15 January 2025.
  5. 5

    Complete nutrition paperwork documenting residents’ morning and afternoon refreshments.

    Stated by Victoria House (Wallasey) LtdStated completedThe respondent said that this action was complete when they made their response on 15 January 2025.

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

Make the conservatory door permanently inaccessible by changing its hinges and removing its opening mechanism and handle.

Verbatim wording from the response

“Conservatory door | Door to be made permanently inaccessible | Management/Providers | | 22.01.25 | Conservatory door made permanently inaccessible by way of change to hinges and removal of opening mechanism and handle. Note: this is not a fire door, the fire door is situated a few feet away”

Source location

Response from Victoria Residential Home
Page 3 · response
Published 15 January 2025

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 structured daily activities for high-risk residents through an activities coordinator working five afternoons per week.

Verbatim wording from the response

“Engaging Activities for High-Risk Residents | Structured, stimulating activities to engage high-risk residents and reduce behaviours that may lead to attempts to leave the Home | Activities co-ordinator with input from Management | | Completed 07/02/2025 | The activities co-ordinator is now in place for 5 afternoons per week to engage with residents in daily activities.”

Source location

Response from Victoria Residential Home
Page 2 · response
Published 15 January 2025

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 and record emergency exit alarm checks at shift changes and daily management checks.

Verbatim wording from the response

“Rigorous Alarm Checks | Regular inspections of all emergency exit alarms to ensure they are functioning correctly. | Team Leader at the start of each shift PLUS management daily | | Already completed | Introduced following the incident and ongoing daily. Now signed for by seniors and handyman daily. Signatures are for checks at 08:00hrs and 20:00 hrs, specifically when shifts are changing.”

Source location

Response from Victoria Residential Home
Page 2 · response
Published 15 January 2025

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

Secure the front entrance and foyer access using electronic fobs and a self-closing door.

Verbatim wording from the response

“Environment Restructuring | Areas to the front of the Home are being restructured to prevent possible future incidents | Providers | | 14/02/2025 | Work has been completed on securing the outside front door to the premises. By electronic fob and self-closer. This now gives a further layer of protection against the possibility of residents on DoI’s leaving the premises. The area leading to the foyer also has restricted access via a fob system.”

Source location

Response from Victoria Residential Home
Page 3 · response
Published 15 January 2025

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 nutrition paperwork documenting residents’ morning and afternoon refreshments.

Verbatim wording from the response

“Improved shift paperwork | New paperwork to evidence that all residents receive morning and afternoon refreshments | Healthcare Assistants | | Completed | Staff complete nutrition forms.”

Source location

Response from Victoria Residential Home
Page 3 · response
Published 15 January 2025

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