PFD report

Susan Elizabeth SAMSON · Prevention of Future Deaths report

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Issued 23 Feb 2026•County Durham and Darlington

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
2

Of 1 recipient

Stated actions
7

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 raised1

  1. Failure to ensure patients can consistently complete a flight of stairs without assistance before discharge
    Part of recurring concern: Failure to ensure safe post-discharge arrangements for vulnerable patients and residentsPart of recurring concern: Unreliable hospital discharge processes
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

    Deliver SOAP note training to Community Physiotherapy, Occupational Therapy and Assistant staff within six weeks, and remaining Physiotherapy and Occupational Therapy staff within four months.

    Stated by County Durham and Darlington NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.

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

  1. Position

    Repeating stair assessments is not always necessary where a patient previously completed one safely and has no additional risk factors.

    Stated by County Durham and Darlington NHS Foundation TrustExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 ensure patients can consistently complete a flight of stairs without assistance before discharge

Wider context from the report

“The Occupational Therapist involved in the deceased's discharge on 1 May 2025 gave evidence that for someone to be assessed as safe to use the stairs on their own, it was not sufficient for them to have managed to complete a set of stairs without assistance on one occasion; it was necessary for the person to demonstrate that they could consistently complete the stairs without assistance. The Occupational Therapist stated that the two successful attempts in the Care Home seemed to be enough to achieve consistency and indicated that if similar circumstances arose today the patient would still be discharged home at the end of the six-week rehabilitation period. I found as a fact that prior to the deceased's discharge on 1 May 2025 the deceased had not demonstrated that she was able to consistently complete a flight of stairs without assistance. I am concerned by the evidence that if similar circumstances arose today the patient would still be discharged. I am concerned that there may be occasions in the future that patients will be discharged before they are able to consistently complete a flight of stairs and that, as a result, a death may occur. ”

Is this part of a recurring concern?

Yes — Failure to ensure safe post-discharge arrangements for vulnerable patients and residents; Unreliable hospital discharge processes.

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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

Deliver SOAP note training to Community Physiotherapy, Occupational Therapy and Assistant staff within six weeks, and remaining Physiotherapy and Occupational Therapy staff within four months.

Verbatim wording from the response

“The documentation relating to the stair attempts undertaken prior to discharge from the intermediate care setting does not clearly confirm that the patient completed the stairs without assistance and lacks sufficient objective assessment and clinical analysis. The Trust requires the use of the recognised SOAP note structure (Subjective, Objective, Assessment and Plan) when recording assessments, which was completed, however the use of the term supervision should have been more clearly defined.”

Source location

Response from County Durham and Darlington NHS Foundation Trust
Page 2 · response
Published 2 March 2026

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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

Repeating stair assessments is not always necessary where a patient previously completed one safely and has no additional risk factors.

Verbatim wording from the response

“It is not always necessary to repeat a stair assessment. The decision should be guided by the clinician’s professional judgement and the patient’s individual risk profile. If a patient has previously completed a stair assessment safely and no additional risk factors are present, repetition is unlikely to be required. However, for individuals with identified risk such as a history of falls, reduced strength or balance, or frailty, repeating the assessment can provide valuable reassurance by demonstrating consistency and safety over time.”

Source location

Response from County Durham and Darlington NHS Foundation Trust
Page 2 · response
Published 2 March 2026

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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.6

  1. 1

    Review current documentation and the electronic record template, identify required amendments, and include a validated home-hazard assessment tool.

    Stated by County Durham and Darlington NHS Foundation TrustStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.
  2. 2

    Continue the existing record-keeping audit to monitor SOAP documentation compliance and identify areas for improvement.

    Stated by County Durham and Darlington NHS Foundation TrustStated completedThe respondent said that this action was complete when they made their response on 2 March 2026.
  3. 3

    Review progress against the actions and address identified deficiencies promptly.

    Stated by Darlington Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.
  4. 4

    Carry out random sampling audits of works and adaptations referrals, considering review and reissue of the referral form if deficiencies are identified.

    Stated by Darlington Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.
  5. 5

    Share learning from this case through briefings within Housing, Adult Social Care and Children’s Social Care departments.

    Stated by Darlington Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.
  6. 6

    Raise awareness of the referral process among Council staff and external health stakeholders, using this case to reinforce learning and timely handling.

    Stated by Darlington Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 2 March 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.2

  1. 1

    The Council could not lawfully enter and install adaptations without the capacitated tenant’s consent.

    Stated by Darlington Borough CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.
  2. 2

    The tenant guide, referral form and email inbox remain appropriate, so no changes to these arrangements are required.

    Stated by Darlington Borough CouncilExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so 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

Review current documentation and the electronic record template, identify required amendments, and include a validated home-hazard assessment tool.

Verbatim wording from the response

“Ms Samson was identified as being at an increased risk of falls, with several contributing factors including frailty and a documented history of previous falls. However, there is insufficient documentation regarding her understanding of these risks and her expressed preferences around discharge. Although elements of falls risk and mitigation are recorded, this information is not consolidated within a single, clearly identifiable document in the current patient record.”

Source location

Response from County Durham and Darlington NHS Foundation Trust
Page 3 · response
Published 2 March 2026

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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 the existing record-keeping audit to monitor SOAP documentation compliance and identify areas for improvement.

Verbatim wording from the response

“In response, the Trust will ensure that SOAP note training is delivered and completed within the next six weeks for all Community Physiotherapy, Occupational Therapy, and Assistant staff, and within four months for all other Physiotherapy and Occupational Therapy staff. In addition, the existing record-keeping audit, which provides assurance regarding compliance with required standards for SOAP documentation will continue to be used to monitor adherence and identify any areas requiring further improvement.”

Source location

Response from County Durham and Darlington NHS Foundation Trust
Page 2 · response
Published 2 March 2026

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 progress against the actions and address identified deficiencies promptly.

Verbatim wording from the response

“6. Ongoing Monitoring and Review”

Source location

Response from Darlington Borough Council
Page 3 · response
Published 2 March 2026

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

Carry out random sampling audits of works and adaptations referrals, considering review and reissue of the referral form if deficiencies are identified.

Verbatim wording from the response

“Random sampling audits will be carried out of the referrals. Should the content of the referrals be of concern then a review of that form will be considered and reissued.”

Source location

Response from Darlington Borough Council
Page 3 · response
Published 2 March 2026

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

Share learning from this case through briefings within Housing, Adult Social Care and Children’s Social Care departments.

Verbatim wording from the response

“Progress against this action will be reviewed by the Council, and any deficiencies will be addressed promptly. Learning from this case will also be shared through briefings within relevant departments [Housing, Adult and Childrens Social Care].”

Source location

Response from Darlington Borough Council
Page 3 · response
Published 2 March 2026

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

Raise awareness of the referral process among Council staff and external health stakeholders, using this case to reinforce learning and timely handling.

Verbatim wording from the response

“The referral form and email inbox for receipt of such referral forms remain appropriate, however, the Council intends to raise awareness of the referral process to ensure that all referrals are dealt with in a timely manner and that any queries in relation to the referral form are raised at the earliest opportunity to avoid any delay.”

Source location

Response from Darlington Borough Council
Page 3 · response
Published 2 March 2026

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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

The Council could not lawfully enter and install adaptations without the capacitated tenant’s consent.

Verbatim wording from the response

“a Council officer and the OT the works/adaptations which were originally scheduled for 14th May 2025 were brought forward to 6th May 2025 and the OT was advised of this date. The Council can confirm that the works were scheduled to be undertaken on 6th May 2025 and an attempt to install the second banister and grabrails was made on that day, but Susan Samson refused access to her property advising it was not convenient for the banister to be installed. As Susan Samson was a capacitated adult, she was within her rights to refuse access, and the Council was unable to lawfully enter and carry out the works in the absence of her consent.”

Source location

Response from Darlington Borough Council
Page 3 · response
Published 2 March 2026

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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

The tenant guide, referral form and email inbox remain appropriate, so no changes to these arrangements are required.

Verbatim wording from the response

“The Council has reviewed the guide for tenants and are satisfied that there are no changes required to this document.”

Source location

Response from Darlington Borough Council
Page 3 · response
Published 2 March 2026

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