PFD report

Keith Graham WHETTON · Prevention of Future Deaths report

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Issued 24 Dec 2019•Staffordshire South

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised2

  1. Failure to request necessary medical attention
    Part of recurring concern: Failure to reliably escalate requests for medical reviewPart of recurring concern: Failure to seek medical attention when a person's condition warrants it
  2. Failure to inform family members promptly about a fall
    Part of recurring concern: Failure to communicate safety-critical care information effectively between care providers and families
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

    Update and implement the home's falls policy and procedure with clearer instructions for unwitnessed falls and post-fall actions.

    Stated by Interhaze LtdStated completedThe respondent said that this action was complete when they made their response on 7 January 2020.

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 request necessary medical attention

Wider context from the report

“You should already be aware of the concerns in this matter. Even if medical attention was not sought for Keith on 7th September it clearly should have been requested on 8th September. We hope that this has now been taken on board by your home. Additionally, family members felt that they should have been informed earlier about Keith’s fall and I wonder if lessons have been learned here as well. ”

Is this part of a recurring concern?

Yes — Failure to reliably escalate requests for medical review; Failure to seek medical attention when a person's condition warrants it.

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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

Failure to inform family members promptly about a fall

Wider context from the report

“You should already be aware of the concerns in this matter. Even if medical attention was not sought for Keith on 7th September it clearly should have been requested on 8th September. We hope that this has now been taken on board by your home. Additionally, family members felt that they should have been informed earlier about Keith’s fall and I wonder if lessons have been learned here as well. ”

Is this part of a recurring concern?

Yes — Failure to communicate safety-critical care information effectively between care providers and families.

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

Update and implement the home's falls policy and procedure with clearer instructions for unwitnessed falls and post-fall actions.

Verbatim wording from the response

“I have also reviewed the policy and procedure of falls within the home and spoken with the regional managers regarding unwitnessed falls and the policy and procedure has now been updated and put in place within the home. The policy is now more robust and has clearer instructions on steps to be taken in the event of a fall.”

Source location

2019-0452-Response-by-Hunters-Lodge-Care-Centre_Redacted
Page 1 · response
Published 7 January 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.4

  1. 1

    Complete falls training for all staff.

    Stated by Interhaze LtdStated completedThe respondent said that this action was complete when they made their response on 7 January 2020.
  2. 2

    Supervise all staff on falls-related safety matters.

    Stated by Interhaze LtdStated completedThe respondent said that this action was complete when they made their response on 7 January 2020.
  3. 3

    Increase staffing levels to improve resident observation and support the nursing team.

    Stated by Interhaze LtdStated completedThe respondent said that this action was complete when they made their response on 7 January 2020.
  4. 4

    Commence additional falls training for trained staff through Remit Training Group.

    Stated by Interhaze LtdStated plannedThe respondent said that this action was planned when they made their response on 7 January 2020.

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

Complete falls training for all staff.

Verbatim wording from the response

“Following the fall all staff have been supervised on the matter and have completed falls training. Trained staff are going to be commenced on additional training via remit training group. I myself and the clinical lead have completed the course and believe it will be beneficial for other senior staff to complete.”

Source location

2019-0452-Response-by-Hunters-Lodge-Care-Centre_Redacted
Page 1 · response
Published 7 January 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

Supervise all staff on falls-related safety matters.

Verbatim wording from the response

“Following the fall all staff have been supervised on the matter and have completed falls training. Trained staff are going to be commenced on additional training via remit training group. I myself and the clinical lead have completed the course and believe it will be beneficial for other senior staff to complete.”

Source location

2019-0452-Response-by-Hunters-Lodge-Care-Centre_Redacted
Page 1 · response
Published 7 January 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

Increase staffing levels to improve resident observation and support the nursing team.

Verbatim wording from the response

“After my trend analysis and internal investigation I have increased staffing levels to increase observation of residents and further support to the nursing team. This level of support has had a positive impact in reducing falls and improving patient safety.”

Source location

2019-0452-Response-by-Hunters-Lodge-Care-Centre_Redacted
Page 1 · response
Published 7 January 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

Commence additional falls training for trained staff through Remit Training Group.

Verbatim wording from the response

“Following the fall all staff have been supervised on the matter and have completed falls training. Trained staff are going to be commenced on additional training via remit training group. I myself and the clinical lead have completed the course and believe it will be beneficial for other senior staff to complete.”

Source location

2019-0452-Response-by-Hunters-Lodge-Care-Centre_Redacted
Page 1 · response
Published 7 January 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