PFD report

Terence Ewart JAMES · Prevention of Future Deaths report

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Issued 17 Dec 2019•Central and South East Kent

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
4

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised4

  1. Failure to hand over fall histories to returning care staff
    Part of recurring concern: Failure to reliably hand over fall informationPart of recurring concern: Unreliable clinical handover processesPart of recurring concern: Unreliable handover of care information and responsibility
  2. Failure to inform attending GPs of falls before clinical attendance
    Part of recurring concern: Failure to reliably hand over fall informationPart of recurring concern: Failure to reliably notify primary care of changes affecting patient carePart of recurring concern: Unreliable post-fall assessment and clinical response
  3. Delays in escalating unwitnessed falls for further medical advice
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

    Implement paper-based handover arrangements across all homes, including comprehensive sheets, senior sign-offs and ongoing monitoring.

    Stated by Charing Dale LimitedStated in progressThe respondent said that this action was in progress when they made their response on 31 December 2019.
  2. Action

    Share inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.

    Stated by Charing Dale LimitedStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.
  3. Action

    Introduce a specific audit of the handover process.

    Stated by Charing Dale LimitedStated plannedThe respondent said that this action was planned when they made their response on 31 December 2019.

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

  1. Position

    The errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.

    Stated by Charing Dale LimitedDisputes 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

Failure to hand over fall histories to returning care staff

Wider context from the report

“(2) The history of the fall on 17th April was not handed over to care staff who had returned from leave on 20th April. ”

Is this part of a recurring concern?

Yes — Failure to reliably hand over fall information; Unreliable clinical handover processes; Unreliable handover of care information and responsibility.

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 inform attending GPs of falls before clinical attendance

Wider context from the report

“(1) The GP was due to attend Mr James on 17th April and was not informed of his fall prior to his attendance. He had bruising and abrasion to his head and was on anticoagulation medication. The GP examined him and found no apparent neurological symptoms or fracture. He advised that if there was any deterioration to seek further urgent advice. The GP evidence was that he would have advised that Mr James be taken to hospital. ”

Is this part of a recurring concern?

Yes — Failure to reliably hand over fall information; Failure to reliably notify primary care of changes affecting patient care; Unreliable post-fall assessment and clinical response.

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

Delays in escalating unwitnessed falls for further medical advice

Wider context from the report

“(4) Mr James sustained a further unwitnessed fall at approximately 10:25 on 20th April. This fall was not escalated for further medical advice until after a change of shift at 19:00 when his deterioration was immediately noted and escalated. ”

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

Failure to escalate reported pain for further medical advice

Wider context from the report

“(3) A chiropodist raised concerns on 18th April that Mr James was in pain and this was not escalated for further medical advice. ”

Is this part of a recurring concern?

Yes — Unreliable escalation by care staff for required medical attention.

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

Implement paper-based handover arrangements across all homes, including comprehensive sheets, senior sign-offs and ongoing monitoring.

Verbatim wording from the response

“However, due to the concerns raised by the Coroner, we are conducting a full review of our handover system. For the time being, we have reverted back to the paper based system for handovers, across all of our homes as it is a visual tool that can be read straight away rather than having to find the appropriate tab on a system to read back in the notes. The system was put in place at Chippendayle Lodge immediately after the inquest on 11 December 2019. It was communicated to staff in internal meetings, and we are ensuring that all staff understand the importance of ensuring the handover forms are completed in full. This is being done through team meetings, which have taken place, for example, on 11 December 2019 and 13 December 2019.”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 3 · response
Published 31 December 2019

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 inquest learning and reinforce escalation, handover and related procedures through manager communications, team meetings and supervision.

Verbatim wording from the response

“A further staff meeting was held on Friday, 13 December 2019, and the manager shared the details of the inquest to ensure that all staff understood the importance of following the systems and protocols in place and to enforce expectations in this respect.”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 3 · response
Published 31 December 2019

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

Introduce a specific audit of the handover process.

Verbatim wording from the response

“As an organisation, we also conduct regular audits. We have a schedule in place in this respect. We are also in the process of introducing a specific audit relating to the handover process, and this will be in place from 29 January 2020, after the managers’ meeting, where it will be discussed. We have endeavoured to put robust systems in place to ensure that errors do not occur again. The above being said, we had in fact put a great deal of thought”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 4 · response
Published 31 December 2019

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 a comprehensive review of the handover system.

Verbatim wording from the response

“However, due to the concerns raised by the Coroner, we are conducting a full review of our handover system. For the time being, we have reverted back to the paper based system for handovers, across all of our homes as it is a visual tool that can be read straight away rather than having to find the appropriate tab on a system to read back in the notes. The system was put in place at Chippendayle Lodge immediately after the inquest on 11 December 2019. It was communicated to staff in internal meetings, and we are ensuring that all staff understand the importance of ensuring the handover forms are completed in full. This is being done through team meetings, which have taken place, for example, on 11 December 2019 and 13 December 2019.”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 3 · response
Published 31 December 2019

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 errors were considered individual judgment calls rather than evidence of systemic failures in existing processes.

Verbatim wording from the response

“into the processes in place before the inquest, and we do believe that where errors occurred, they were individual judgment calls, rather than systemic errors.”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 5 · response
Published 31 December 2019

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

Further escalation after the fall was considered unnecessary because the resident was already on the GP list and showed no immediate concern.

Verbatim wording from the response

“On this particular occasion, Mr James was already on the list to be seen by the GP, for another concern. Therefore, there was no reason to put him on the list following the fall, as he was already on the list and there was no immediate concern at that time because he had got himself up from the floor and back into bed. The GP would not come out earlier in these circumstances, as the GP has to attend to the patients in the surgery before coming out to the home. The only other option would have been to escalate the incident to an emergency and call 999. This fall was not deemed to be an emergency, and the GP also confirmed that Mr James did not require urgent intervention when he attended. As an organisation, we are under a duty not to escalate the matter unnecessarily, as this inevitably places further pressure on emergency services.”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 2 · response
Published 31 December 2019

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 GP escalation process cannot be unilaterally changed because it is driven by national general-practice arrangements.

Verbatim wording from the response

“their associated GP surgery. Furthermore, we are not able to unilaterally change this process, as it is driven by national GP arrangements.”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 2 · response
Published 31 December 2019

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.1

  1. 1

    Review and update organisational policies and procedures.

    Stated by Charing Dale LimitedStated completedThe respondent said that this action was complete when they made their response on 31 December 2019.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Records do not indicate that the chiropodist raised concerns, and the chiropodist did not give evidence confirming otherwise.

    Stated by Charing Dale LimitedDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 organisational policies and procedures.

Verbatim wording from the response

“In any event, we are always keen to review and revise our policies and procedures where appropriate and we do conduct systematic and rolling reviews as an organisation. Therefore, we have ensured robust systems are in place and that these have been fully reviewed, and updated accordingly.”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 5 · response
Published 31 December 2019

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

Records do not indicate that the chiropodist raised concerns, and the chiropodist did not give evidence confirming otherwise.

Verbatim wording from the response

“We understand there is a factual dispute regarding whether the chiropodist did raise concerns and who these concerns were raised with. Our records document the chiropodist’s visit, but do not indicate concerns were raised and the chiropodist was not called to give evidence at the inquest to ask further detail in this respect.”

Source location

2019-0430-Response-from-Charing-Healthcare-Redacted-1
Page 4 · response
Published 31 December 2019

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