PFD report

Anthony Haydn WOOD · Prevention of Future Deaths report

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Issued 3 Jun 2025•South London

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. Lack of crash mats at the side of the bed
    Part of recurring concern: Unreliable fall-mat safety controls
  2. Failure to provide two staff members when preparing patients to be washed and changed
  3. Failure to keep the bed rail up when a patient is attended by a lone HCA
    Part of recurring concern: Unreliable bedrail safety controls
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

Lack of crash mats at the side of the bed

Wider context from the report

“(1) the patient was identified as at high risk of a fall (2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur) (3) there were no crash mats at the side of his bed (4) it was known that the patient had a propensity to push staff when being changed (5) the bed-rail was not up when the patient was attended by a HCA acting alone (6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed (7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed All of these matters are recorded in the Trust's own Datix report. ”

Is this part of a recurring concern?

Yes — Unreliable fall-mat safety controls.

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 provide two staff members when preparing patients to be washed and changed

Wider context from the report

“(1) the patient was identified as at high risk of a fall (2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur) (3) there were no crash mats at the side of his bed (4) it was known that the patient had a propensity to push staff when being changed (5) the bed-rail was not up when the patient was attended by a HCA acting alone (6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed (7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed All of these matters are recorded in the Trust's own Datix report. ”

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 keep the bed rail up when a patient is attended by a lone HCA

Wider context from the report

“(1) the patient was identified as at high risk of a fall (2) he was deemed to be severely frail (and hence at corresponding risk, if a fall were to occur) (3) there were no crash mats at the side of his bed (4) it was known that the patient had a propensity to push staff when being changed (5) the bed-rail was not up when the patient was attended by a HCA acting alone (6) that HCA was unable, on his own, to hold on to the patient, in order to prevent him from falling out of bed (7) the patient should have had the assistance of two members of staff, and not just one, when being prepared to be washed and changed All of these matters are recorded in the Trust's own Datix report. ”

Is this part of a recurring concern?

Yes — Unreliable bedrail safety controls.

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