PFD report

Rebecca Gilbank · Prevention of Future Deaths report

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Issued 26 Jul 2016•Surrey

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
3

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 carry out required checks when staff are occupied with other service users
    Part of recurring concern: Failure to carry out required overnight checks
  2. Lack of staff knowledge about obtaining an outside telephone line to emergency services
    Part of recurring concern: Failure to ensure care staff can initiate appropriate emergency callsPart of recurring concern: Unreliable access to emergency communication
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.3

  1. Action

    Remove the requirement to dial 9 for an outside telephone line.

    Stated by Independence HomesStated completedThe respondent said that this action was complete when they made their response on 26 July 2016.
  2. Action

    Communicate the changed outside-line procedure to staff verbally, by email and in the communications book.

    Stated by Independence HomesStated completedThe respondent said that this action was complete when they made their response on 26 July 2016.
  3. Action

    Review available night staffing resources at services.

    Stated by Independence HomesStated completedThe respondent said that this action was complete when they made their response on 26 July 2016.

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

  1. Position

    Local authorities or CCGs are responsible for arranging and funding higher staffing ratios required by assessed needs.

    Stated by Independence HomesRedirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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 carry out required checks when staff are occupied with other service users

Wider context from the report

“Lack of check at 1.30am on 12 May 2015 Evidence at inquest revealed that the check was not carried out because the two members of waking night staff were busy dealing with other service users. The court heard evidence that this was not an isolated occurrence and that checks had been missed on other occasions in circumstances in which staff were dealing with other service users. ”

Is this part of a recurring concern?

Yes — Failure to carry out required overnight checks.

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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

Lack of staff knowledge about obtaining an outside telephone line to emergency services

Wider context from the report

“Lack of knowledge about how to obtain an outside telephone line Evidence at the inquest revealed that the staff on duty did not know how to obtain an outside line to emergency services and, after trying, had to rely on a personal mobile phone. This resulted in a delay of unknown duration. ”

Is this part of a recurring concern?

Yes — Failure to ensure care staff can initiate appropriate emergency calls; Unreliable access to emergency communication.

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

Remove the requirement to dial 9 for an outside telephone line.

Verbatim wording from the response

“Independence Homes has taken action in relation to this matter. At a meeting on 14 July 2016, at which we considered the evidence provided during the inquest, we immediately sought to rectify the issue of dialling 9 for an outside line from some of our locations. On 26 July 2016 we contacted our telephone provider and we changed our contract so that there is no longer a need to dial 9 to obtain an outside line. This change was communicated to staff verbally, by email on 7 September 2016 and in the Clareville Lodge Communications Book. Please find a copy of the email enclosed.”

Source location

2016-0266-Response-by-Independence-Homes
Page 3 · response
Published 26 July 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

Communicate the changed outside-line procedure to staff verbally, by email and in the communications book.

Verbatim wording from the response

“Independence Homes has taken action in relation to this matter. At a meeting on 14 July 2016, at which we considered the evidence provided during the inquest, we immediately sought to rectify the issue of dialling 9 for an outside line from some of our locations. On 26 July 2016 we contacted our telephone provider and we changed our contract so that there is no longer a need to dial 9 to obtain an outside line. This change was communicated to staff verbally, by email on 7 September 2016 and in the Clareville Lodge Communications Book. Please find a copy of the email enclosed.”

Source location

2016-0266-Response-by-Independence-Homes
Page 3 · response
Published 26 July 2016

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 available night staffing resources at services.

Verbatim wording from the response

“We have considered the staff resources that are available at our services during the night. We believe that sufficient waking night staff are made available at our services. If an individual’s assessed needs mean that they require one to one support or a higher ratio of waking night staff to service users, we note that it is the responsibility of the local authority or CCG to arrange a care and support package which meets those assessed needs and to fund it appropriately.”

Source location

2016-0266-Response-by-Independence-Homes
Page 3 · response
Published 26 July 2016

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

Local authorities or CCGs are responsible for arranging and funding higher staffing ratios required by assessed needs.

Verbatim wording from the response

“We have considered the staff resources that are available at our services during the night. We believe that sufficient waking night staff are made available at our services. If an individual’s assessed needs mean that they require one to one support or a higher ratio of waking night staff to service users, we note that it is the responsibility of the local authority or CCG to arrange a care and support package which meets those assessed needs and to fund it appropriately.”

Source location

2016-0266-Response-by-Independence-Homes
Page 3 · response
Published 26 July 2016

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

Clear guidance on obtaining an outside telephone line was already provided at the time of the death.

Verbatim wording from the response

“I note that, at the time of Ms Gilbank’s death, clear and accessible guidance on how to obtain an outside line was provided. I understand that there was a sign on the noticeboard in the staff office at Clareville Lodge which stated that staff should dial 9 for an outside line.”

Source location

2016-0266-Response-by-Independence-Homes
Page 3 · response
Published 26 July 2016

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

Existing waking-night staffing is considered sufficient for assessed needs.

Verbatim wording from the response

“We have considered the staff resources that are available at our services during the night. We believe that sufficient waking night staff are made available at our services. If an individual’s assessed needs mean that they require one to one support or a higher ratio of waking night staff to service users, we note that it is the responsibility of the local authority or CCG to arrange a care and support package which meets those assessed needs and to fund it appropriately.”

Source location

2016-0266-Response-by-Independence-Homes
Page 3 · response
Published 26 July 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