PFD report

Vera SPENCER · Prevention of Future Deaths report

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Issued 11 Nov 2024•Derby and Derbyshire

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
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 raised2

  1. Unavailability of an out-of-hours local falls service or team
    Part of recurring concern: Unreliable post-fall assessment and clinical response
  2. Delays in ambulance attendance for people who have fallen at home
    Part of recurring concern: Delays in ambulance attendance
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.2

  1. Action

    Implement area-wide options to further mitigate the risk of prolonged waits on the floor after a fall.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 November 2024.
  2. Action

    Continue multi-agency work with local authorities and voluntary-sector partners to minimise ambulance response times.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.

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

  1. Position

    Proposed alternative out-of-hours responders cannot safely recover people with suspected hip fractures because they have only seated-lifter equipment; ambulance attendance remains necessary.

    Stated by NHS Derby and Derbyshire Integrated Care BoardUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Unavailability of an out-of-hours local falls service or team

Wider context from the report

“At times when the ambulance service is under extreme pressure, individuals who have fallen at home can wait many hours on the floor before paramedics can attend. This is usually because falls are given a lower categorisation by the ambulance service because it is not a life-threatening situation. Resultant long lies can increase the risk of pneumonia, pressure damage and Rhabdomyolysis. The court heard evidence that other than the ambulance service, there is no local falls service or team operating out of hours to assess patients and assist them off the floor following a fall. ”

Is this part of a recurring concern?

Yes — Unreliable post-fall assessment and clinical response.

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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

Delays in ambulance attendance for people who have fallen at home

Wider context from the report

“At times when the ambulance service is under extreme pressure, individuals who have fallen at home can wait many hours on the floor before paramedics can attend. This is usually because falls are given a lower categorisation by the ambulance service because it is not a life-threatening situation. Resultant long lies can increase the risk of pneumonia, pressure damage and Rhabdomyolysis. The court heard evidence that other than the ambulance service, there is no local falls service or team operating out of hours to assess patients and assist them off the floor following a fall. ”

Is this part of a recurring concern?

Yes — Delays in ambulance attendance.

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

Implement area-wide options to further mitigate the risk of prolonged waits on the floor after a fall.

Verbatim wording from the response

“Further options that the ICB will consider for alternative ambulance response out of hours:”

Source location

Response from Derby NHS ICB
Page 2 · response
Published 11 November 2024

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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

Continue multi-agency work with local authorities and voluntary-sector partners to minimise ambulance response times.

Verbatim wording from the response

“In this critical incident the local NHS worked together with the local authorities and the voluntary sector to reduce the response times for patients in the community. In the short term we will continue to work as a multi-agency group to try and minimise response times by EMAS. In the medium term we recognise that we will need to identify ways in which the demand for healthcare and healthcare beds can be reduced. This will require a blended approach that looks at:”

Source location

Response from Derby NHS ICB
Page 3 · response
Published 11 November 2024

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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

Proposed alternative out-of-hours responders cannot safely recover people with suspected hip fractures because they have only seated-lifter equipment; ambulance attendance remains necessary.

Verbatim wording from the response

“Option A: DHU have staff trained in falls recovery as they provide some cover for the Team Up / UCR provision. Their falls response provision could be extended to cover 20:00-08:00, and Team Up and step-up virtual wards would provide the continuation of clinical support next day. If this was in situ, this individual could have been responded to by a team, observations completed, ambulance need confirmed through on-screen head to toe assessment, perhaps an urgent visit arranged from DHU medic for pain relief. It is likely that with a hip fracture suspected, the responders would not be able to safely lift the individual off the floor (teams only have seated lifter equipment). This option would offer the person in person support, confirmation of need and pain and other symptom management, but not remove the need for ambulance attendance in this case.”

Source location

Response from Derby NHS ICB
Page 2 · response
Published 11 November 2024

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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.4

  1. 1

    Roll out Optica locally to reduce hospital length of stay.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
  2. 2

    Continue working with social and voluntary care services to speed discharge of people who are ready to return home.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated in progressThe respondent said that this action was in progress when they made their response on 11 November 2024.
  3. 3

    Identify ways to reduce healthcare demand and bed requirements through a blended prevention, hospital-flow and discharge approach.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 November 2024.
  4. 4

    Accelerate development and rollout of an area-wide falls prevention service, including consideration of support for injurious falls, through 2025/26 planning and prioritisation.

    Stated by NHS Derby and Derbyshire Integrated Care BoardStated plannedThe respondent said that this action was planned when they made their response on 11 November 2024.

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

Roll out Optica locally to reduce hospital length of stay.

Verbatim wording from the response

“2. Improving flow through our acute sector and reducing length of stay in hospital beds. In the short term we have the local roll out of a technology known as Optica that has a proven ability to reduce length of stay in hospital settings”

Source location

Response from Derby NHS ICB
Page 3 · response
Published 11 November 2024

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

Continue working with social and voluntary care services to speed discharge of people who are ready to return home.

Verbatim wording from the response

“3. Continued working with social and voluntary care services to improve the speed of discharge of people when they are well back to their usual home setting.”

Source location

Response from Derby NHS ICB
Page 3 · response
Published 11 November 2024

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

Identify ways to reduce healthcare demand and bed requirements through a blended prevention, hospital-flow and discharge approach.

Verbatim wording from the response

“In this critical incident the local NHS worked together with the local authorities and the voluntary sector to reduce the response times for patients in the community. In the short term we will continue to work as a multi-agency group to try and minimise response times by EMAS. In the medium term we recognise that we will need to identify ways in which the demand for healthcare and healthcare beds can be reduced. This will require a blended approach that looks at:”

Source location

Response from Derby NHS ICB
Page 3 · response
Published 11 November 2024

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

Accelerate development and rollout of an area-wide falls prevention service, including consideration of support for injurious falls, through 2025/26 planning and prioritisation.

Verbatim wording from the response

“Action 1: Derby & Derbyshire ICB will seek to accelerate the development and roll out of a falls prevention service that is available to all residents in Derby & Derbyshire that includes consideration of an injurious falls service. This will be considered through the local NHS planning & prioritisation process for 2025/26.”

Source location

Response from Derby NHS ICB
Page 1 · response
Published 11 November 2024

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