PFD report

Walter Gordon Powley · Prevention of Future Deaths report

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Issued 4 Oct 2013•Leicester City and South Leicestershire

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
3

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
12

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 of regular external inspections to recognize relevant physical safety matters
    Part of recurring concern: Failure of external safety inspections to identify physical safety deficiencies
  2. Failure to cover or otherwise maintain safe temperatures for exposed heating pipes and valves
  3. Lack of risk assessment of room-specific physical safety for individual 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.8

  1. Action

    Review the way adult social care inspections are conducted.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2013.
  2. Action

    Pilot a new adult social care inspection methodology using five assessment domains.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 4 October 2013.
  3. Action

    Explore how the new inspection methodology can ensure inspectors check high-risk areas.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2013.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.5

  1. Position

    The provider has ultimate responsibility for identifying and monitoring unsafe conditions and taking appropriate action.

    Stated by Care Quality CommissionRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking 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 of regular external inspections to recognize relevant physical safety matters

Wider context from the report

“3.Western Park View had been inspected by the Care Quality Commission and the Local Authority on a regular basis. Evidence indicated that these matters referred to had not been recognized by those bodies. ”

Is this part of a recurring concern?

Yes — Failure of external safety inspections to identify physical safety deficiencies.

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 cover or otherwise maintain safe temperatures for exposed heating pipes and valves

Wider context from the report

“1.Neither the pipes that he fell against nor the valves that connected those pipes to the radiator, were covered. HSE published guidance indicated that the maximum temperature of such pipes should be 43 degrees centigrade. Readings taken from uncovered pipes both in Mr Powley’s room and other rooms in the Home indicated that the temperatures ranged between 60 degrees centigrade and more than 70 degrees centigrade. Evidence was given at the Inquest that a number of other residential homes in this area did not have pipes and valves covered. It may well be therefore that this applies throughout the country. ”

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

Lack of risk assessment of room-specific physical safety for individual residents

Wider context from the report

“2.It was therefore also apparent that there had not been a risk assessment of the physical circumstances in that room, and whether it was therefore safe for a particular resident. ”

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

Review the way adult social care inspections are conducted.

Verbatim wording from the response

“Our local compliance inspector did inspect the location in May 2012 and reviewed seven outcomes or regulations. Unfortunately they did not inspect against Regulation 15, Outcome 10. We are currently reviewing the way in which we inspect in adult social care and are piloting a new methodology very soon. Instead of the current outcomes we will be assessing against five domains and ask five questions:”

Source location

2013-0251-Response-by-Care-Quality-Commission
Page 2 · response
Published 4 October 2013

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

Pilot a new adult social care inspection methodology using five assessment domains.

Verbatim wording from the response

“Our local compliance inspector did inspect the location in May 2012 and reviewed seven outcomes or regulations. Unfortunately they did not inspect against Regulation 15, Outcome 10. We are currently reviewing the way in which we inspect in adult social care and are piloting a new methodology very soon. Instead of the current outcomes we will be assessing against five domains and ask five questions:”

Source location

2013-0251-Response-by-Care-Quality-Commission
Page 2 · response
Published 4 October 2013

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

Explore how the new inspection methodology can ensure inspectors check high-risk areas.

Verbatim wording from the response

“I welcome the timeliness of your report and will share its findings within my organisation; there are definitely lessons to be learnt from this very sad situation, which includes exploring the ways in which we can work more closely with the HSE and how we can ensure, within our new methodology, that our inspectors are checking high-risk areas such as this.”

Source location

2013-0251-Response-by-Care-Quality-Commission
Page 2 · response
Published 4 October 2013

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

Continue advising members to assess radiator and pipework risks and maintain safe radiator temperatures and coverings.

Verbatim wording from the response

“I do, however, recognise the risk which you have identified and I can report that, as an Association, we regularly advise members of their responsibility under the Health & Safety at Work Act. We particularly draw their attention to the need to ensure that the pipes leading to a radiator, as well as the radiator itself, are suitably covered to prevent the risk of burns in the event of a patient falling against the radiator.”

Source location

2013-0251-Response-by-RNHA
Page 1 · response
Published 4 October 2013

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

Share the concerns and response with local-authority health and safety regulators through the Local Authority Unit.

Verbatim wording from the response

“HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those covering prevention of burns, not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. I will share this letter with local authority health and safety regulators via HSE’s Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum.”

Source location

2013-0251-Response-by-Health-Safety-Executive
Page 2 · response
Published 4 October 2013

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

Map relevant social-care safety standards and explore how they can best be promulgated through an established task-and-finish group.

Verbatim wording from the response

“HSE has also just launched a GB Social Care Partners Forum (SCPF) which brings together regulators, care home representatives and other stakeholders. The aim of the Forum is to raise standards by producing broadly agreed guidance and disseminating it to the sector. HSE sees this as appropriate forum to raise your concerns and it is our intention to raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting. It is hoped that the next meeting will be held in February 2014. One of the task and finish groups that has been established is looking at mapping standards and exploring how these can best be promulgated as your concerns no doubt apply to other established standards.”

Source location

2013-0251-Response-by-Health-Safety-Executive
Page 2 · response
Published 4 October 2013

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

Raise the risks from hot surfaces and pipework at the next Social Care Partners Forum meeting.

Verbatim wording from the response

“HSE has also just launched a GB Social Care Partners Forum (SCPF) which brings together regulators, care home representatives and other stakeholders. The aim of the Forum is to raise standards by producing broadly agreed guidance and disseminating it to the sector. HSE sees this as appropriate forum to raise your concerns and it is our intention to raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting. It is hoped that the next meeting will be held in February 2014. One of the task and finish groups that has been established is looking at mapping standards and exploring how these can best be promulgated as your concerns no doubt apply to other established standards.”

Source location

2013-0251-Response-by-Health-Safety-Executive
Page 2 · response
Published 4 October 2013

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

Review and update the Health and Safety Executive’s care-home safety booklet, HSG220.

Verbatim wording from the response

“HSE has guidance on the risks from hot water and surfaces on its Health and Social Care web pages (http://www.hse.gov.uk/healthservices/scalding-burning.htm), including Information Sheet 6. Further information can also be found in HSE booklet ‘Health and safety in care homes’ (HSG220) which is available on the website and is currently being reviewed and updated. It is hoped that the revised version will be available in early Spring 2014.”

Source location

2013-0251-Response-by-Health-Safety-Executive
Page 2 · response
Published 4 October 2013

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

The provider has ultimate responsibility for identifying and monitoring unsafe conditions and taking appropriate action.

Verbatim wording from the response

“The provider has the ultimate responsibility for ensuring that they know and monitor any unsafe conditions in the service and take the correct action.”

Source location

2013-0251-Response-by-Care-Quality-Commission
Page 2 · response
Published 4 October 2013

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

Regulatory follow-up is assigned to the CQC and HSE, which have the necessary regulatory powers.

Verbatim wording from the response

“I see that your report has also been sent to David Bean at CQC and Steve Scott at HSE, both of whom have regulatory powers which I am sure that they will now exercise as necessary.”

Source location

2013-0251-Response-by-RNHA
Page 1 · response
Published 4 October 2013

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

Regulatory action concerning the non-member care home is outside the Association’s authority.

Verbatim wording from the response

“The Registered Nursing Home Association is a trade association for owners of care homes providing nursing care (previously called nursing homes). There is no obligation placed upon anyone who joins the Registered Nursing Home Association. The powers of the Association are limited to membership matters, i.e. removing membership where the standards expected of the Association are not met.”

Source location

2013-0251-Response-by-RNHA
Page 1 · response
Published 4 October 2013

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

Local authorities enforce health and safety in non-nursing residential care, including relevant standards and compliance concerns.

Verbatim wording from the response

“HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those covering prevention of burns, not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. I will share this letter with local authority health and safety regulators via HSE’s Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum.”

Source location

2013-0251-Response-by-Health-Safety-Executive
Page 2 · response
Published 4 October 2013

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

CQC is the lead regulator and inspection body better placed to proactively lead on health and social care service-user safety.

Verbatim wording from the response

“I totally understand your concerns but see CQC as the lead regulator and inspection body in England for health and social care providers and we believe they are better placed to proactively lead on service user safety issues. I note that you have also written to CQC.”

Source location

2013-0251-Response-by-Health-Safety-Executive
Page 2 · response
Published 4 October 2013

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

    Explore closer working with the Health and Safety Executive.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 4 October 2013.
  2. 2

    Share the report’s findings within the organisation.

    Stated by Care Quality CommissionStated plannedThe respondent said that this action was planned when they made their response on 4 October 2013.
  3. 3

    Arrange discussion of the concerns at the next national local-authority practitioner forum meeting.

    Stated by Health and Safety ExecutiveStated plannedThe respondent said that this action was planned when they made their response on 4 October 2013.
  4. 4

    Launch and operate the GB Social Care Partners Forum to bring regulators, care providers and stakeholders together on social-care safety.

    Stated by Health and Safety ExecutiveStated completedThe respondent said that this action was complete when they made their response on 4 October 2013.

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

Explore closer working with the Health and Safety Executive.

Verbatim wording from the response

“I welcome the timeliness of your report and will share its findings within my organisation; there are definitely lessons to be learnt from this very sad situation, which includes exploring the ways in which we can work more closely with the HSE and how we can ensure, within our new methodology, that our inspectors are checking high-risk areas such as this.”

Source location

2013-0251-Response-by-Care-Quality-Commission
Page 2 · response
Published 4 October 2013

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

Share the report’s findings within the organisation.

Verbatim wording from the response

“I welcome the timeliness of your report and will share its findings within my organisation; there are definitely lessons to be learnt from this very sad situation, which includes exploring the ways in which we can work more closely with the HSE and how we can ensure, within our new methodology, that our inspectors are checking high-risk areas such as this.”

Source location

2013-0251-Response-by-Care-Quality-Commission
Page 2 · response
Published 4 October 2013

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

Arrange discussion of the concerns at the next national local-authority practitioner forum meeting.

Verbatim wording from the response

“HSE does not routinely inspect health and social care providers but does investigate serious incidents meeting our selection criteria and inspect where there is evidence of poor compliance. This may include, for example, where there is evidence of established standards, such as those covering prevention of burns, not being followed. This is also the case for non-nursing residential care which is enforced by local authorities. I will share this letter with local authority health and safety regulators via HSE’s Local Authority Unit and also arrange for the matter to be discussed at the next meeting of the national local authority practitioner forum.”

Source location

2013-0251-Response-by-Health-Safety-Executive
Page 2 · response
Published 4 October 2013

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

Launch and operate the GB Social Care Partners Forum to bring regulators, care providers and stakeholders together on social-care safety.

Verbatim wording from the response

“HSE has also just launched a GB Social Care Partners Forum (SCPF) which brings together regulators, care home representatives and other stakeholders. The aim of the Forum is to raise standards by producing broadly agreed guidance and disseminating it to the sector. HSE sees this as appropriate forum to raise your concerns and it is our intention to raise the issue of assessing the risk from hot surfaces and pipe-work at the next meeting. It is hoped that the next meeting will be held in February 2014. One of the task and finish groups that has been established is looking at mapping standards and exploring how these can best be promulgated as your concerns no doubt apply to other established standards.”

Source location

2013-0251-Response-by-Health-Safety-Executive
Page 2 · response
Published 4 October 2013

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