PFD report

Lilian Hursell · Prevention of Future Deaths report

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Issued 1 Apr 2016•Mid Kent and Medway

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
1

Of 1 recipient

Stated actions
7

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 fully engage cot-side retaining buttons
    Part of recurring concern: Unreliable safety controls for cots and cot sides
  2. Failure to assess injuries after a significant uncontrolled fall before repositioning the patient
    Part of recurring concern: Failure to assess and respond promptly to significant signs of injuryPart of recurring concern: Failure to reliably assess and diagnose injuriesPart of recurring concern: Unreliable post-fall assessment and clinical response
  3. Failure to use safe post-fall handling for patients with possible head or cervical spine injury
    Part of recurring concern: Unsafe moving and handling of patients
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.5

  1. Action

    Retrain all care-delivering staff in moving and handling through e-learning and competency-based workbooks.

    Stated by Rch Care Homes LimitedStated in progressThe respondent said that this action was in progress when they made their response on 1 April 2016.
  2. Action

    Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.

    Stated by Rch Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 1 April 2016.
  3. Action

    Audit bedrails through maintenance checks and management rechecks to confirm secure locking with an audible click.

    Stated by Rch Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 1 April 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

Failure to fully engage cot-side retaining buttons

Wider context from the report

“(1) The mechanism to hold the cotsides (bedrails) in a vertical position comprise a retaining button in a sliding vertical rail which engages with a corresponding hole in a static rail. Whilst this mechanism operates safely when the mechanism is properly engaged which is established by an audible click, staff at the care home had experienced occasions when the cotsides retaining button had not been fully engaged when the cotside had been raised to prevent a resident falling from the bed rendering the cotside unstable and at risk of lowering inadvertently. ”

Is this part of a recurring concern?

Yes — Unreliable safety controls for cots and cot sides.

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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

Failure to assess injuries after a significant uncontrolled fall before repositioning the patient

Wider context from the report

“(2) Nursing and healthcare staff moved a patient onto her back and placed a pillow under her head when the patient had suffered a significant uncontrolled fall onto her face and the extent of her injuries had not been assessed. It was known at the time that this happened that she had suffered a head trauma as she had a bleeding injury to her forehead, she had however additionally suffered a subdural haematoma and had fractures to her cervical vertebra ”

Is this part of a recurring concern?

Yes — Failure to assess and respond promptly to significant signs of injury; Failure to reliably assess and diagnose injuries; Unreliable post-fall assessment and clinical response.

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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

Failure to use safe post-fall handling for patients with possible head or cervical spine injury

Wider context from the report

“(2) Nursing and healthcare staff moved a patient onto her back and placed a pillow under her head when the patient had suffered a significant uncontrolled fall onto her face and the extent of her injuries had not been assessed. It was known at the time that this happened that she had suffered a head trauma as she had a bleeding injury to her forehead, she had however additionally suffered a subdural haematoma and had fractures to her cervical vertebra ”

Is this part of a recurring concern?

Yes — Unsafe moving and handling of patients.

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

Retrain all care-delivering staff in moving and handling through e-learning and competency-based workbooks.

Verbatim wording from the response

“• A programme of moving and handling re-training has been commenced and will be completed by the 1st June 2016, this is carried out in the blended approach of e-learning and via competency based workbooks for all staff delivering care.”

Source location

Hursell-Response
Page 1 · response
Published 1 April 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

Instruct all staff not to move a person after a fall until a suitably trained person completes a full assessment.

Verbatim wording from the response

“• All staff have been advised that following a fall no person should be moved until a full assessment by a suitably trained person has been carried out.”

Source location

Hursell-Response
Page 2 · response
Published 1 April 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

Audit bedrails through maintenance checks and management rechecks to confirm secure locking with an audible click.

Verbatim wording from the response

“• A thorough system of bedrail audits has been introduced to ensure all bedrails lock with an audible click into the safety bracket. This entails an audit via the maintenance operative to check for safety and security which is then rechecked by the home manager.”

Source location

Hursell-Response
Page 1 · response
Published 1 April 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

Re-educate staff in bedrail use through direct supervision to ensure locking mechanisms are properly engaged.

Verbatim wording from the response

“• Staff have been re-educated in bed rail use in order to ensure the locking mechanism is properly engaged. This was done via a process of direct supervisions.”

Source location

Hursell-Response
Page 1 · response
Published 1 April 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

Provide daily-meeting health and safety briefings reinforcing the risks of unsecured bedrails, recorded in meeting minutes and supervision records.

Verbatim wording from the response

“• Staff have received health and safety briefings in daily meetings to reiterate the potential dangers of not ensuring bed rails are locked in position. This is recorded via staff meeting minutes and direct supervisions.”

Source location

Hursell-Response
Page 2 · response
Published 1 April 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.2

  1. 1

    Retrain all care staff in first aid through accredited, competency-based training and monitor compliance.

    Stated by Rch Care Homes LimitedStated in progressThe respondent said that this action was in progress when they made their response on 1 April 2016.
  2. 2

    Retrain staff in health and safety through accredited, competency-based training with independent invigilation.

    Stated by Rch Care Homes LimitedStated in progressThe respondent said that this action was in progress when they made their response on 1 April 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

Retrain all care staff in first aid through accredited, competency-based training and monitor compliance.

Verbatim wording from the response

“• A programme of re-training in first aid has been commenced and will be completed by the 1st June 2016. The training is delivered via City and Guilds accredited learning and via a competency based workbook for all the care staff, this is monitored for compliance by the Head of Quality and Compliance.”

Source location

Hursell-Response
Page 1 · response
Published 1 April 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

Retrain staff in health and safety through accredited, competency-based training with independent invigilation.

Verbatim wording from the response

“• A programme of health and safety retraining has been commenced and will be completed by the 1st June 2016. This is been done via City and Guilds accredited training and competency based workbooks which are independently invigilated.”

Source location

Hursell-Response
Page 1 · response
Published 1 April 2016

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