PFD report

Edna Drury Evans · Prevention of Future Deaths report

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Issued 27 Sep 2019•North Wales (East and Central)

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
1

Named on the report

Responses found
0

Of 1 recipient

Stated actions
0

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 to categorise residents with repeated falls as high risk
    Part of recurring concern: Inadequate control of falls risks
  2. Failure to reassess residents' falls risk following further falls
    Part of recurring concern: Inadequate control of falls risks
  3. Incomplete staff training in falls-risk management
    Part of recurring concern: Inadequate control of falls risks
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

No linked response statements

No respondent-stated action or position is clearly linked to these concerns.

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 categorise residents with repeated falls as high risk

Wider context from the report

“The evidence provided at the inquest indicated that staff at the home were currently undergoing training in relation to the risk of falls but that this had not yet been fully completed. Furthermore, although the manager indicated in her evidence that a resident who had sustained a number of falls would be expected to be categorised as “high risk”, she stated that Mrs Evans was only a “medium risk” despite the fact that she had falls prior to admission and continued to have a number of falls whilst a resident. Although there was an assessment of Mrs Evans on the 11th of January (ie shortly after she became a resident) there is no evidence to suggest that there was any reassessment following further falls nor any apparent policy or protocol requiring this. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 reassess residents' falls risk following further falls

Wider context from the report

“The evidence provided at the inquest indicated that staff at the home were currently undergoing training in relation to the risk of falls but that this had not yet been fully completed. Furthermore, although the manager indicated in her evidence that a resident who had sustained a number of falls would be expected to be categorised as “high risk”, she stated that Mrs Evans was only a “medium risk” despite the fact that she had falls prior to admission and continued to have a number of falls whilst a resident. Although there was an assessment of Mrs Evans on the 11th of January (ie shortly after she became a resident) there is no evidence to suggest that there was any reassessment following further falls nor any apparent policy or protocol requiring this. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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

Incomplete staff training in falls-risk management

Wider context from the report

“The evidence provided at the inquest indicated that staff at the home were currently undergoing training in relation to the risk of falls but that this had not yet been fully completed. Furthermore, although the manager indicated in her evidence that a resident who had sustained a number of falls would be expected to be categorised as “high risk”, she stated that Mrs Evans was only a “medium risk” despite the fact that she had falls prior to admission and continued to have a number of falls whilst a resident. Although there was an assessment of Mrs Evans on the 11th of January (ie shortly after she became a resident) there is no evidence to suggest that there was any reassessment following further falls nor any apparent policy or protocol requiring this. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

Open source report
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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