PFD report

Arthur Edward JOHNSON · Prevention of Future Deaths report

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Issued 5 Jan 2021•Hampshire, Portsmouth and Southampton

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
2

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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Concerns raised2

  1. Insufficient training for residential home staff in recognising intracranial injury
    Part of recurring concern: Unreliable emergency response arrangements in care homes
  2. Lack of clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury
    Part of recurring concern: Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuriesPart of recurring concern: Failure to assess and respond promptly to significant signs of injuryPart of recurring concern: Unreliable escalation policy for care concernsPart of recurring concern: Unreliable post-fall assessment and clinical response
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.2

  1. Action

    Require residential staff to complete a standalone learning module on falls management, including the risk of head injury.

    Stated by Hampshire County CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
  2. Action

    Review and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.

    Stated by Hampshire County CouncilStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.

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

Insufficient training for residential home staff in recognising intracranial injury

Wider context from the report

“Oakridge House Residential Home is staffed by non-medically trained personnel. The “Post-Falls” process/policy direct that 999/111 should be called when a head injury is suspected. The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called. My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury. It is not clear when 999/111 should be called. Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury. ”

Is this part of a recurring concern?

Yes — Unreliable emergency response arrangements in care homes.

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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 clear direction in the post-falls process on when to call 999/111 for possible or suspected head injury

Wider context from the report

“Oakridge House Residential Home is staffed by non-medically trained personnel. The “Post-Falls” process/policy direct that 999/111 should be called when a head injury is suspected. The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called. My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury. It is not clear when 999/111 should be called. Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury. ”

Is this part of a recurring concern?

Yes — Failure of head injury assessment and treatment pathways to reliably recognise and manage head injuries; Failure to assess and respond promptly to significant signs of injury; Unreliable escalation policy for care concerns; Unreliable post-fall assessment and clinical response.

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

Require residential staff to complete a standalone learning module on falls management, including the risk of head injury.

Verbatim wording from the response

“Regarding staff training, previously staff were trained in how to respond to head injury events during our “Emergency Aid” course. Following your comments, this has been reviewed. Although staff working in a residential setting are not clinically trained, they will now be required to participate in a standalone learning module designed specifically to focus on falls management issues, including risk of head injury. This will compliment other practice guidance for example risk assessment and risk management plans for mobile elderly people in a communal living setting.”

Source location

2021-0003-Response-from-Hampshire-County-Council-Redacted
Page 1 · response
Published 14 January 2021

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 and update the falls protocol in line with current NICE guidance, directing staff to contact 999 or 111.

Verbatim wording from the response

“I understand that when you requested the documentation for Mr Johnson’s inquest, you received only part of the current “falls protocol”. As a result of your recommendations the entire protocol has been reviewed and updated in line with current NICE guidance. This clearly directs staff to contact 999 or 111. The revised protocol is attached and I trust addresses the concern relating to the clarity of practice guidance.”

Source location

2021-0003-Response-from-Hampshire-County-Council-Redacted
Page 1 · response
Published 14 January 2021

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