PFD report

Malcolm Bennett · Prevention of Future Deaths report

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Issued 22 Jun 2016•Manchester South

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
8

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

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Report evidence summary

Concerns raised1

  1. Delays in arranging emergency hospital assessment and transport after suspected significant injury
    Part of recurring concern: Failure to assess and respond promptly to significant signs of injuryPart of recurring concern: Failure to call an ambulance promptly when emergency assistance is requiredPart of recurring concern: Failure to provide timely emergency hospital conveyancePart of recurring concern: Unreliable emergency access to hospital care
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.1

  1. Action

    Update risk management plans for residents prescribed anticoagulants to require calling 999 immediately after a fall, accident or injury.

    Stated by Borough Care LtdStated in progressThe respondent said that this action was in progress when they made their response on 22 June 2016.

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 arranging emergency hospital assessment and transport after suspected significant injury

Wider context from the report

“In the care Plan for this person, it clearly indicated that in the event of any significant injury he should be taken as expeditiously as possible to the Emergency Dept. of the hospital. Clearly this was not done, in that the staff left him knowing that he had apparently been hit by someone and he might well be injured, and they did not call for an ambulance for another three hours. In the light of his cause of death, this delay might have been contributory. ”

Is this part of a recurring concern?

Yes — Failure to assess and respond promptly to significant signs of injury; Failure to call an ambulance promptly when emergency assistance is required; Failure to provide timely emergency hospital conveyance; Unreliable emergency access to hospital care.

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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

Update risk management plans for residents prescribed anticoagulants to require calling 999 immediately after a fall, accident or injury.

Verbatim wording from the response

“1. All Home Managers in each of Borough Care's care homes were instructed to update the risk management plans (which form part of a care plan) for all residents who have been prescribed Warfarin or any other anti-coagulant, with an instruction to ring 999 without delay in the event that a resident has, or is suspected of, having had a fall, accident or injury. Registered Managers at all care homes have been asked to confirm that risk management plans for residents prescribed with such medication have now been updated.”

Source location

2016-0232-Response-by-Borough-Care
Page 1 · response
Published 22 June 2016

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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.7

  1. 1

    Place anticoagulant warnings on the care plans and MAR sheets of all residents prescribed anticoagulants.

    Stated by Borough Care LtdStated completedThe respondent said that this action was complete when they made their response on 22 June 2016.
  2. 2

    Revise medication and First Aid training to include anticoagulant use.

    Stated by Borough Care LtdStated completedThe respondent said that this action was complete when they made their response on 22 June 2016.
  3. 3

    Remind Silverdale care staff through supervision about following care plans and related safety requirements.

    Stated by Borough Care LtdStated completedThe respondent said that this action was complete when they made their response on 22 June 2016.
  4. 4

    Discuss residents prescribed anticoagulants at staff handovers and team meetings, including reference to their care plans.

    Stated by Borough Care LtdStated completedThe respondent said that this action was complete when they made their response on 22 June 2016.
  5. 5

    Brief senior staff at Silverdale about the matters of concern.

    Stated by Borough Care LtdStated completedThe respondent said that this action was complete when they made their response on 22 June 2016.
  6. 6

    Review and update the Falls Prevention and Reporting of Accidents policy and procedure by the end of September 2016.

    Stated by Borough Care LtdStated plannedThe respondent said that this action was planned when they made their response on 22 June 2016.
  7. 7

    Review and revise the medication audit procedure by the end of September 2016.

    Stated by Borough Care LtdStated plannedThe respondent said that this action was planned when they made their response on 22 June 2016.

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

Place anticoagulant warnings on the care plans and MAR sheets of all residents prescribed anticoagulants.

Verbatim wording from the response

“2.1 Each resident who has been prescribed with an anti-coagulant now has an anti-coagulant warning placed on their care plan and MAR sheet to highlight the fact that the resident is prescribed such medication.”

Source location

2016-0232-Response-by-Borough-Care
Page 1 · response
Published 22 June 2016

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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

Revise medication and First Aid training to include anticoagulant use.

Verbatim wording from the response

“2.3 General medication training for staff administering medication has been reviewed to include anti-coagulant use and First Aid training has also been revised to include same.”

Source location

2016-0232-Response-by-Borough-Care
Page 1 · response
Published 22 June 2016

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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

Remind Silverdale care staff through supervision about following care plans and related safety requirements.

Verbatim wording from the response

“2. The Home Manager at Silverdale met with the senior team to brief them of the matters of concern, and in addition key individuals have received a formal ‘note of concern’ regarding their failure to follow the care plan for Mr Bennett. All care staff at the care home have been reminded of the importance of such matters through the staff supervision process.”

Source location

2016-0232-Response-by-Borough-Care
Page 1 · response
Published 22 June 2016

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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

Discuss residents prescribed anticoagulants at staff handovers and team meetings, including reference to their care plans.

Verbatim wording from the response

“2.2 Information about residents who are prescribed anti-coagulant medication is discussed at staff handovers and team meetings, including reference to the care plan.”

Source location

2016-0232-Response-by-Borough-Care
Page 1 · response
Published 22 June 2016

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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

Brief senior staff at Silverdale about the matters of concern.

Verbatim wording from the response

“2. The Home Manager at Silverdale met with the senior team to brief them of the matters of concern, and in addition key individuals have received a formal ‘note of concern’ regarding their failure to follow the care plan for Mr Bennett. All care staff at the care home have been reminded of the importance of such matters through the staff supervision process.”

Source location

2016-0232-Response-by-Borough-Care
Page 1 · response
Published 22 June 2016

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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

Review and update the Falls Prevention and Reporting of Accidents policy and procedure by the end of September 2016.

Verbatim wording from the response

“2.4 Borough Care's ‘Falls Prevention and Reporting of Accidents’ policy and procedure will be reviewed and updated by the end of September 2016.”

Source location

2016-0232-Response-by-Borough-Care
Page 1 · response
Published 22 June 2016

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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

Review and revise the medication audit procedure by the end of September 2016.

Verbatim wording from the response

“2.5 Borough Care's medication audit procedure will be reviewed and revised by the end of September 2016.”

Source location

2016-0232-Response-by-Borough-Care
Page 2 · response
Published 22 June 2016

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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Official responses located
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Data last updated 7 September 2026