PFD report

Peter Pattinson · Prevention of Future Deaths report

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Issued 6 Sep 2013•Sunderland

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
6

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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 raised6

  1. Failure to act on family concerns and requests about bed rails
    Part of recurring concern: Failure to acknowledge and act on family and carer safety concerns in patient carePart of recurring concern: Unreliable bedrail safety controls
  2. Failure to risk assess family concerns and bed-rail requests
    Part of recurring concern: Failure to acknowledge and act on family and carer safety concerns in patient carePart of recurring concern: Unreliable bedrail safety controls
  3. Missing daily statements from patient files
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

    Number all documentation pages for daily statements to prevent pages being mislaid and ensure sequential pagination.

    Stated by European CareStated completedThe respondent said that this action was complete when they made their response on 6 September 2013.
  2. Action

    Require immediate reporting and repair of bed-rail defects, with staff instructed on reporting routes during and outside office hours.

    Stated by European CareStated completedThe respondent said that this action was complete when they made their response on 6 September 2013.
  3. Action

    Carry out bed-rail risk assessments within 24 hours of admission and review them monthly or when residents’ needs change.

    Stated by European CareStated completedThe respondent said that this action was complete when they made their response on 6 September 2013.

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 act on family concerns and requests about bed rails

Wider context from the report

“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

Is this part of a recurring concern?

Yes — Failure to acknowledge and act on family and carer safety concerns in patient care; Unreliable bedrail 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 risk assess family concerns and bed-rail requests

Wider context from the report

“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

Is this part of a recurring concern?

Yes — Failure to acknowledge and act on family and carer safety concerns in patient care; Unreliable bedrail 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

Missing daily statements from patient files

Wider context from the report

“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

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 document family concerns and bed-rail requests

Wider context from the report

“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

Is this part of a recurring concern?

Yes — Failure to acknowledge and act on family and carer safety concerns in patient care; Unreliable bedrail 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

Delays in repairing bed rails

Wider context from the report

“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

Is this part of a recurring concern?

Yes — Unreliable bedrail 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 paginate daily statements sequentially

Wider context from the report

“1. The concerns expressed by the family and their requests for Mr Pattinson’s bed rails to be raised were not acted upon or documented, and were not subject to a risk assessment. 2. The repair to the bed rails of Mr Pattinson’s bed was not actioned in a timely way. 3. There were missing daily statements from the file (27th November 2012 18:00 hrs to 29th November 2012 18:30 hrs) 4. The daily statements that were provided were not paginated sequentially. ”

Is this part of a recurring concern?

Yes — Incomplete, inaccurate or unavailable clinical and care records.

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

Number all documentation pages for daily statements to prevent pages being mislaid and ensure sequential pagination.

Verbatim wording from the response

“All documentation relating to daily statements used are now numbered so pages cannot be mislaid.”

Source location

2013-0250-Response-by-European-Care-Group
Page 2 · response
Published 6 September 2013

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

Require immediate reporting and repair of bed-rail defects, with staff instructed on reporting routes during and outside office hours.

Verbatim wording from the response

“b. any defects regarding bed rails are to be reported and repaired immediately. All staff are now aware of how to report defects both within office hours and out of hours; and”

Source location

2013-0250-Response-by-European-Care-Group
Page 2 · response
Published 6 September 2013

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

Carry out bed-rail risk assessments within 24 hours of admission and review them monthly or when residents’ needs change.

Verbatim wording from the response

“a. bed rail risk assessments are carried out within 24 hours of admission and are then reviewed monthly or when needs change. Any changes will be discussed with the service user or a family member; and”

Source location

2013-0250-Response-by-European-Care-Group
Page 1 · response
Published 6 September 2013

Open published response

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.3

  1. 1

    Train staff in safe bed-rail use, require policy acknowledgement, sign off competencies, retain records, and monitor understanding through supervision.

    Stated by European CareStated plannedThe respondent said that this action was planned when they made their response on 6 September 2013.
  2. 2

    Undertake monthly bed-rail maintenance in accordance with policy and retain maintenance records.

    Stated by European CareStated plannedThe respondent said that this action was planned when they made their response on 6 September 2013.
  3. 3

    Implement daily senior-staff visual checks of bed rails, record findings at handover, and require manager verification.

    Stated by European CareStated completedThe respondent said that this action was complete when they made their response on 6 September 2013.

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

Train staff in safe bed-rail use, require policy acknowledgement, sign off competencies, retain records, and monitor understanding through supervision.

Verbatim wording from the response

“b. all present staff in post will undertake training in the safe usage of bed rails and read European Care’s “Safe Use of Bed Rails” policy, signing to confirm they understand the policy. All new staff will undertake this training as part of their induction and understand European Care’s policy on the safe use of bed rails. Competencies for all staff will be signed off by the manager, training coordinator and clinical lead and a record kept on their personnel file. Continuous understanding will be monitored in supervisions.”

Source location

2013-0250-Response-by-European-Care-Group
Page 1 · response
Published 6 September 2013

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

Undertake monthly bed-rail maintenance in accordance with policy and retain maintenance records.

Verbatim wording from the response

“c. maintenance of bed rails will be undertaken monthly in accordance with European Care policy by the maintenance manager and a record of this maintenance will be kept.”

Source location

2013-0250-Response-by-European-Care-Group
Page 2 · response
Published 6 September 2013

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

Implement daily senior-staff visual checks of bed rails, record findings at handover, and require manager verification.

Verbatim wording from the response

“a. a daily checking system is now in place for a senior member of staff to visually check the condition of the bed rails and record this on the handover. This in turn is checked by the manager;”

Source location

2013-0250-Response-by-European-Care-Group
Page 1 · response
Published 6 September 2013

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