PFD report

Mildred Horrex · Prevention of Future Deaths report

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Issued 8 Jun 2020•West Sussex

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
1

Of 1 recipient

Stated actions
9

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. Inadequate fall risk assessments
    Part of recurring concern: Inadequate control of falls risks
  2. Failure of monthly medication audits to detect recording discrepancies
    Part of recurring concern: Failure of care and safety auditing to identify deficienciesPart of recurring concern: Failure to assure the quality of clinical and care records
  3. Failure to maintain accurate medication administration records
    Part of recurring concern: Incomplete, inaccurate or unavailable clinical and care records
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.7

  1. Action

    Record admission-related telephone calls to preserve relevant information about residents’ history and needs.

    Stated by Pelham houseStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
  2. Action

    Restructure the pre-admission assessment process, expand forms to capture activities of daily living, and obtain family sign-off.

    Stated by Pelham houseStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.
  3. Action

    Implement a care-plan system containing risk assessments, audit trails, and resident-relative access to current care information.

    Stated by Pelham houseStated completedThe respondent said that this action was complete when they made their response on 13 August 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    The available admission information supported a sufficient falls risk assessment, disputing that inadequate information caused an insufficient assessment.

    Stated by Pelham houseDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Inadequate fall risk assessments

Wider context from the report

“1. During the course of the Inquest it was clear that overall the record keeping in respect of Mildred was poor. There was insufficient information taken about Mildred by the home before her admission to Pelham House, the information that was taken was at times inaccurate and this lead to an inadequate fall risk assessment being insufficient. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 of monthly medication audits to detect recording discrepancies

Wider context from the report

“2. Whilst the drugs chart showed that Mildred was taking her medication regularly the amount of medication that was found after her death showed that this could not be the case. We were told that monthly drugs audits were apparently carried out but they did not pick up the discrepancies in the recording on the drugs charts and the amount of medication held. ”

Is this part of a recurring concern?

Yes — Failure of care and safety auditing to identify deficiencies; Failure to assure the quality of clinical and care records.

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 accurate medication administration records

Wider context from the report

“2. Whilst the drugs chart showed that Mildred was taking her medication regularly the amount of medication that was found after her death showed that this could not be the case. We were told that monthly drugs audits were apparently carried out but they did not pick up the discrepancies in the recording on the drugs charts and the amount of medication held. ”

Is this part of a recurring concern?

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

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 obtain sufficient and accurate information before admission

Wider context from the report

“1. During the course of the Inquest it was clear that overall the record keeping in respect of Mildred was poor. There was insufficient information taken about Mildred by the home before her admission to Pelham House, the information that was taken was at times inaccurate and this lead to an inadequate fall risk assessment being insufficient. ”

Is this part of a recurring concern?

Yes — Unreliable safety assessment of new care-home residents on admission.

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

Record admission-related telephone calls to preserve relevant information about residents’ history and needs.

Verbatim wording from the response

“to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of the MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives wish to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 2 · response
Published 13 August 2020

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

Restructure the pre-admission assessment process, expand forms to capture activities of daily living, and obtain family sign-off.

Verbatim wording from the response

“Pelham house response of actions taken. POINT 1 Pelham house restructured the whole pre-assessment process the paper work was updated and now reflects all aspects of an individual’s ADL as well as the existing questions (this was already in place just with some more information areas”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 1 · response
Published 13 August 2020

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 a care-plan system containing risk assessments, audit trails, and resident-relative access to current care information.

Verbatim wording from the response

“to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of the MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives wish to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 2 · response
Published 13 August 2020

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

Obtain patient summaries from GPs for current and newly admitted residents.

Verbatim wording from the response

“POINT 2 medication Medication is audited monthly CCG / Kamsons pharmacy myself and the GP have worked together to ensure safe practices are ongoing. Home manager Audits internally alongside the deputy manager and there is a visible summary at the end of the audit to highlight any potential concerns. External auditor also audits medication and administration when he visits. There is ongoing support from the CCG and Kamsons pharmacy After a request from myself GPs now provide patient summaries for all residents that are currently in Pelham house and coming in to Pelham house.”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 2 · response
Published 13 August 2020

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

Conduct monthly medication audits with internal management oversight, visible summaries, and external review of medication administration.

Verbatim wording from the response

“POINT 2 medication Medication is audited monthly CCG / Kamsons pharmacy myself and the GP have worked together to ensure safe practices are ongoing. Home manager Audits internally alongside the deputy manager and there is a visible summary at the end of the audit to highlight any potential concerns. External auditor also audits medication and administration when he visits. There is ongoing support from the CCG and Kamsons pharmacy After a request from myself GPs now provide patient summaries for all residents that are currently in Pelham house and coming in to Pelham house.”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 2 · response
Published 13 August 2020

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 care plans and risk assessments monthly and after significant changes, with relatives signing care-plan reviews.

Verbatim wording from the response

“to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of the MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives wish to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 2 · response
Published 13 August 2020

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

Employ an external auditor to conduct monthly care-plan and medication audits and provide additional advice when needed.

Verbatim wording from the response

“to highlight and family members are now signing the pre-assessment forms to agree to what has been documented) family members continue to sit with management and go through the individuals life and health history the family still continue to assist with the care planning with the individual present so we can get a good understanding of need, we also now have recorded calls something that would have been very beneficial at the time of the MH arrival and passing, we also have a new care plan system that is recognised by CQC and this is working very well and has all information risk assessments and an audit trail, it allows a gateway should relatives wish to log in and see what’s happening on a daily basis, Pelham house also employs an external auditor who comes to audit monthly and sooner where needed and is always available for advice all care plans and risk assessments are reviewed”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 2 · response
Published 13 August 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The available admission information supported a sufficient falls risk assessment, disputing that inadequate information caused an insufficient assessment.

Verbatim wording from the response

“Response Prior to admission the family had a meeting with the manager of the home and the deputy manager, they themselves provided all the information to us everything they believed relevant, my deputy questioned them about falls history and they said mum is NOT a high risk of falling having only one fall whilst in her own home, all information was provided by themselves, the risk assessment was sufficient at the time it was extremely difficult to explain the workings of the system in a court room with individuals that have never used a care plan system before I believe this is why the coroner made the comment about record keeping, ( the paramedic in the court room understood perfectly well as he was familiar with the system) the system we used took the information provided by the family and generated a falls score, MH had not fallen in Pelham prior to her death and this meant that a”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 1 · response
Published 13 August 2020

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.2

  1. 1

    Assess medication-administration competency and provide recurring medication training, refresher questionnaires, and online learning for care staff.

    Stated by Pelham houseStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.
  2. 2

    Work with the CCG, pharmacy, and GP to maintain safe medication practices.

    Stated by Pelham houseStated in progressThe respondent said that this action was in progress when they made their response on 13 August 2020.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    A falls referral was not considered necessary because there had been no prior fall at the home and referrals followed two or more falls.

    Stated by Pelham houseNo action considered necessaryThe respondent said that no further action was needed.

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

Assess medication-administration competency and provide recurring medication training, refresher questionnaires, and online learning for care staff.

Verbatim wording from the response

“Response At the time of this incident visual medication spot checks were carried out by the Deputy Manager along with daily audits and monthly summaries. Assessing the competency of Senior staff administering medication is ongoing with a Senior member of staff that is a trained medical assessor and promotes in house training. Policies and procedures covering medication in the Home are well documented and accessible by all staff. Questionnaires on medication relating to the policies and procedures are used in the home as refresher tools for all care staff and all staff have training twice a year and an online course.”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 1 · response
Published 13 August 2020

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

Work with the CCG, pharmacy, and GP to maintain safe medication practices.

Verbatim wording from the response

“POINT 2 medication Medication is audited monthly CCG / Kamsons pharmacy myself and the GP have worked together to ensure safe practices are ongoing. Home manager Audits internally alongside the deputy manager and there is a visible summary at the end of the audit to highlight any potential concerns. External auditor also audits medication and administration when he visits. There is ongoing support from the CCG and Kamsons pharmacy After a request from myself GPs now provide patient summaries for all residents that are currently in Pelham house and coming in to Pelham house.”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 2 · response
Published 13 August 2020

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

A falls referral was not considered necessary because there had been no prior fall at the home and referrals followed two or more falls.

Verbatim wording from the response

“Response Prior to admission the family had a meeting with the manager of the home and the deputy manager, they themselves provided all the information to us everything they believed relevant, my deputy questioned them about falls history and they said mum is NOT a high risk of falling having only one fall whilst in her own home, all information was provided by themselves, the risk assessment was sufficient at the time it was extremely difficult to explain the workings of the system in a court room with individuals that have never used a care plan system before I believe this is why the coroner made the comment about record keeping, ( the paramedic in the court room understood perfectly well as he was familiar with the system) the system we used took the information provided by the family and generated a falls score, MH had not fallen in Pelham prior to her death and this meant that a”

Source location

2020-0126-Response-from-Pelham-House.pdf
Page 1 · response
Published 13 August 2020

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