PFD report

Olive Wilmott · Prevention of Future Deaths report

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Issued 21 Jun 2016•Nottinghamshire

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
4

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 raised4

  1. Failure to make Safeguarding referrals for suspected abuse or neglect
    Part of recurring concern: Failure to act appropriately on safeguarding referrals and notices
  2. Failure to effectively investigate suspected pushing incidents
    Part of recurring concern: Inadequate safety incident investigations
  3. Insufficient overnight staffing for dementia unit residents’ needs
    Part of recurring concern: Insufficient care-home staffing capacity for residents’ required carePart of recurring concern: Insufficient safe staffing and senior cover out of hours
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

Failure to make Safeguarding referrals for suspected abuse or neglect

Wider context from the report

“1. That there were references in the medical records to Miss Wilmott possibly having been pushed, but no or no effective investigation of the circumstances was made at the time and no Safeguarding referral was made. ”

Is this part of a recurring concern?

Yes — Failure to act appropriately on safeguarding referrals and notices.

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 effectively investigate suspected pushing incidents

Wider context from the report

“1. That there were references in the medical records to Miss Wilmott possibly having been pushed, but no or no effective investigation of the circumstances was made at the time and no Safeguarding referral was made. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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

Insufficient overnight staffing for dementia unit residents’ needs

Wider context from the report

“2. That Miss Wilmott was assessed as requiring observation at 15 minute intervals, but there was no evidence that this had been in place and at the time of the event there were insufficient staff in place for her and other residents’ needs (one staff member dedicated per floor of the dementia unit during the night shift). ”

Is this part of a recurring concern?

Yes — Insufficient care-home staffing capacity for residents’ required care; Insufficient safe staffing and senior cover out of hours.

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 maintain required 15-minute observation of residents

Wider context from the report

“2. That Miss Wilmott was assessed as requiring observation at 15 minute intervals, but there was no evidence that this had been in place and at the time of the event there were insufficient staff in place for her and other residents’ needs (one staff member dedicated per floor of the dementia unit during the night shift). ”

Is this part of a recurring concern?

Yes — Failure to reliably supervise and monitor residents in care accommodation; Unreliable patient observation arrangements.

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