PFD report

Agostino COSTA · Prevention of Future Deaths report

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Issued 3 Dec 2013•Inner North London

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
3

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

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Concerns raised3

  1. Lack of clarity among staff about falls risk classification
    Part of recurring concern: Unreliable objective criteria for safety risk assessment
  2. Failure to share root cause analysis learning with relevant staff
    Part of recurring concern: Failure to identify and address recurring safety issues through organisational learningPart of recurring concern: Failure to reliably disseminate contextualised safety learning to relevant staffPart of recurring concern: Unreliable root cause analysis processesPart of recurring concern: Unreliable staff access to and understanding of safety-critical guidance
  3. Failure to ensure staff competence in managing patients after falls
    Part of recurring concern: Inadequate control of falls risksPart of recurring concern: Unreliable post-fall assessment and clinical responsePart of recurring concern: Unsafe assignment of staff without the required qualifications or competence to care work
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

Lack of clarity among staff about falls risk classification

Wider context from the report

“1. There was confusion among the staff as to whether Mr Costa was classified as red (high risk) or green (low risk) in terms of falls. 2. There was confusion among the staff as to whether a patient walking with a frame presents a high risk of falls. 3. There was confusion among the staff as to whether a patient with myelofibrosis and blood transfusions presents a high risk of falls. This confusion was also present in the hospital root cause analysis conducted after Mr Costa’s death. ”

Is this part of a recurring concern?

Yes — Unreliable objective criteria for safety risk assessment.

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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 share root cause analysis learning with relevant staff

Wider context from the report

“4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls. 5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some. I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff. ”

Is this part of a recurring concern?

Yes — Failure to identify and address recurring safety issues through organisational learning; Failure to reliably disseminate contextualised safety learning to relevant staff; Unreliable root cause analysis processes; Unreliable staff access to and understanding of safety-critical guidance.

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 ensure staff competence in managing patients after falls

Wider context from the report

“4. The junior doctor present did not know how to deal with a patient post fall on the ward, though he had dealt with patients in the emergency unit who had fallen in the community. He had not attended the hospital training seminar on falls. 5. The hospital root cause analysis was not shared with all relevant members of staff, though it was signed off at the beginning of August. Thus learning points from it were completely lost to some. I heard that a great deal of work is being done in your trust to attempt to prevent falls and appropriately to treat patients when falls have occurred, but attendance at one of the monthly seminars run by the lead doctor for falls is not mandatory for all staff. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks; Unreliable post-fall assessment and clinical response; Unsafe assignment of staff without the required qualifications or competence to care work.

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