PFD report

Rita Howells · Prevention of Future Deaths report

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Issued 19 Jul 2024•Herefordshire

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. Failure to complete falls assessments before routinely erecting bed rails
    Part of recurring concern: Inadequate control of falls risks
  2. Unsatisfactory procedures for establishing whether call bells are working
    Part of recurring concern: Unreliable call bell systems for summoning assistance
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.7

  1. Action

    Complete an in-depth audit of bedrail-related falls, assessment compliance, bedrail positioning and observation compliance.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.
  2. Action

    Implement a standardised process and frequency for checking inpatient call bells and reporting faults.

    Stated by Wye Valley NHS TrustStated plannedThe respondent said that this action was planned when they made their response on 31 July 2024.
  3. Action

    Add digital call-bell check prompts and establish weekly housekeeper call-bell checks.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.

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 falls assessments before routinely erecting bed rails

Wider context from the report

“(1) Contrary to Policy as advised, bed rails are routinely erected before Falls Assessment ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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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

Unsatisfactory procedures for establishing whether call bells are working

Wider context from the report

“(2) The procedures to establish whether a call bell is working are unsatisfactory ”

Is this part of a recurring concern?

Yes — Unreliable call bell systems for summoning assistance.

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

Complete an in-depth audit of bedrail-related falls, assessment compliance, bedrail positioning and observation compliance.

Verbatim wording from the response

“4. Bespoke audit as part of Quality Improvement”

Source location

Response from Wye Valley NHS Trust
Page 3 · response
Published 31 July 2024

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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

Implement a standardised process and frequency for checking inpatient call bells and reporting faults.

Verbatim wording from the response

“Ward areas perform checks of the call bell system and report issues directly to Sodexo, who undertake any remedial works. Upon review, the checks vary in frequency across different wards and are not subject to a standardised checking process. A standard approach will be implemented in response to this regulation 28.”

Source location

Response from Wye Valley NHS Trust
Page 4 · response
Published 31 July 2024

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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

Add digital call-bell check prompts and establish weekly housekeeper call-bell checks.

Verbatim wording from the response

“As part of the improvements to our digital nurse noting, a review of all assessments (questions, layout, and functionality) has been ongoing for a number of months. A number of changes are being implemented to improve the risk assessments associated with falls, bedrails and level of observation. This will simplify and combine these assessments to ensure completion at the same time. Given the inconsistency with call bell checks a prompt for a check of the call bell has been added to the digital system and additionally as a safety net, the housekeeper will perform a weekly check.”

Source location

Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024

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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

Implement weekly senior-nurse reviews of falls assessments and associated prevention measures in community hospitals.

Verbatim wording from the response

“The community hospital settings have implemented ‘Falls Friday’ where the senior nurse reviews all patient falls assessments and ensures they are up to date, accurate and that all measures are in place as per the assessment outcome.”

Source location

Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024

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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

Trial securing bedrails in the down position until a registered nurse completes and supports raising the bedrails assessment.

Verbatim wording from the response

“The most recent initiative is a trial of securing bed rails in the down position (with a yellow cable tie) until the bed rails assessment has been completed. The cable ties will be applied once the bed space has been cleaned and can only be removed by a registered nurse who has undertaken the risk assessment that identifies the need for the rails to be raised. The initiative will be monitored through the routine audits outlined above to ascertain whether this results in a reduction in falls and improvement with correct bed rail positioning.”

Source location

Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024

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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

Redesign digital falls, bedrails and observation assessments to simplify and combine their completion.

Verbatim wording from the response

“As part of the improvements to our digital nurse noting, a review of all assessments (questions, layout, and functionality) has been ongoing for a number of months. A number of changes are being implemented to improve the risk assessments associated with falls, bedrails and level of observation. This will simplify and combine these assessments to ensure completion at the same time. Given the inconsistency with call bell checks a prompt for a check of the call bell has been added to the digital system and additionally as a safety net, the housekeeper will perform a weekly check.”

Source location

Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024

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 bedrails policy in line with national patient-safety guidance.

Verbatim wording from the response

“Trust bed rails policy The Trust bedrails policy supports staff to ensure the safety of patients using bed rails whilst promoting their independence and respecting their right to make their own decisions about their care. It clearly details how to reduce potential harm to patients caused by falling from beds or becoming trapped in bed rails. It gives guidance to support patients, carers and staff to make individual decisions around the risk of using and not using bed rails and suggests alternatives to the use of bed rails where their use may prove more hazardous to the patient than not using them. The policy gives instruction relating to standardised practice concerning the assessment, supply and fitting of bed rails and clarifies the responsibilities of individuals regarding safe and appropriate use of bed rails in all settings across the Trust.”

Source location

Response from Wye Valley NHS Trust
Page 2 · response
Published 31 July 2024

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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

    Roll out visible yellow socks and wristbands identifying patients at risk of falls across community hospitals and acute inpatient wards.

    Stated by Wye Valley NHS TrustStated in progressThe respondent said that this action was in progress when they made their response on 31 July 2024.
  2. 2

    Add falls risk and bedrail position to every-shift nursing handovers and display bedspace reminders about correct bedrail positioning.

    Stated by Wye Valley NHS TrustStated completedThe respondent said that this action was complete when they made their response on 31 July 2024.

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

Roll out visible yellow socks and wristbands identifying patients at risk of falls across community hospitals and acute inpatient wards.

Verbatim wording from the response

“The Frailty Unit have implemented yellow socks and wristbands as a visible and clear identifier that a patient is at risk of falls. This has raised awareness of the risk and has demonstrably seen the number of falls reduce. This initiative is now being rolled out in community hospitals and wider acute inpatient wards.”

Source location

Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024

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

Add falls risk and bedrail position to every-shift nursing handovers and display bedspace reminders about correct bedrail positioning.

Verbatim wording from the response

“Falls risk and bed rail position has been added to the nursing handover sheet and communicated at handover of every shift and new posters displayed in every bed space to remind staff to check the correct bed rail position.”

Source location

Response from Wye Valley NHS Trust
Page 5 · response
Published 31 July 2024

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