PFD report

Peter Scott · Prevention of Future Deaths report

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Issued 5 Oct 2015•North Wales (East and Central)

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
1

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

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Concerns raised1

  1. Lack of a documented process for escalating incidents or concerns to multidisciplinary review of risk assessments and care plans
    Part of recurring concern: Failure to escalate patient issues to multidisciplinary review
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.1

  1. Action

    Implement and continue evaluating the alert and incident process for changes in residents’ physical conditions and behaviour, including escalation, handovers, follow-up and reporting files.

    Stated by Nant-Y-Gaer Hall LtdStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2015.

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 a documented process for escalating incidents or concerns to multidisciplinary review of risk assessments and care plans

Wider context from the report

“The Registered Individual responsible for the care home and the current Manager both acknowledged that within current systems and protocols operating at the home, there is no documented process by which incidents or concerns are escalated so as to result in a multi disciplinary team meeting aimed at reviewing the risk assessments and care plan relating to the vulnerable person within their care. ”

Is this part of a recurring concern?

Yes — Failure to escalate patient issues to multidisciplinary review.

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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

Implement and continue evaluating the alert and incident process for changes in residents’ physical conditions and behaviour, including escalation, handovers, follow-up and reporting files.

Verbatim wording from the response

“In order to fully comply with the regulation 28 we have addressed our alert system. This will alert all staff to changes in our residents’ physical conditions and their behaviours. The new system is self-explanatory (please see copy’s sent - initially a simple alert form is completed by whoever first identifies the concern; this is then evaluated by the qualified nurse in charge and is escalated by the nurse (please see copies sent). This process gives clear instruction throughout the alert process and will inevitably reduce risk and involve the wider disciplinary team immediately if necessary. This remains a work in progress and it will be evaluated and amended to what is working and what is not. All staff have undergone a training session and undergone a supervision session on the changes.”

Source location

2015-0398-Response-by-Nant-Y-Gaer-Hall
Page 1 · response
Published 5 October 2015

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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

    Display alert-process posters throughout the home to inform families and visitors how concerns and alerts are handled.

    Stated by Nant-Y-Gaer Hall LtdStated completedThe respondent said that this action was complete when they made their response on 5 October 2015.
  2. 2

    Train and supervise all staff on the revised policy and alert procedure, confirming that staff have read and understood them.

    Stated by Nant-Y-Gaer Hall LtdStated completedThe respondent said that this action was complete when they made their response on 5 October 2015.

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

Display alert-process posters throughout the home to inform families and visitors how concerns and alerts are handled.

Verbatim wording from the response

“The new system of raising an alert is supported by posters placed around the building for family’s and visitors to be aware of how we deal with concerns and alerts. (Incidents and accidents are also covered within the alert process and form part of the new policy).”

Source location

2015-0398-Response-by-Nant-Y-Gaer-Hall
Page 1 · response
Published 5 October 2015

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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

Train and supervise all staff on the revised policy and alert procedure, confirming that staff have read and understood them.

Verbatim wording from the response

“In order to fully comply with the regulation 28 we have addressed our alert system. This will alert all staff to changes in our residents’ physical conditions and their behaviours. The new system is self-explanatory (please see copy’s sent - initially a simple alert form is completed by whoever first identifies the concern; this is then evaluated by the qualified nurse in charge and is escalated by the nurse (please see copies sent). This process gives clear instruction throughout the alert process and will inevitably reduce risk and involve the wider disciplinary team immediately if necessary. This remains a work in progress and it will be evaluated and amended to what is working and what is not. All staff have undergone a training session and undergone a supervision session on the changes.”

Source location

2015-0398-Response-by-Nant-Y-Gaer-Hall
Page 1 · response
Published 5 October 2015

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