PFD report

Sylvia GIBSON · Prevention of Future Deaths report

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Issued 27 Oct 2022•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
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 raised1

  1. Lack of systems for conveying important information to healthcare professionals
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

    Require staff to contact appropriate medical professionals, pass observations for clinical advice, and document and follow the advice after a fall.

    Stated by Lambton HouseStated completedThe respondent said that this action was complete when they made their response on 31 October 2022.

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 systems for conveying important information to healthcare professionals

Wider context from the report

“Although staff at Lambton House Care Home were aware of her fall in the early hours of 17th August, and this information was handed over to other staff, the same information was not conveyed to the doctor who visited Sylvia (being “not her usual self”) at around lunchtime that day. It appears that no systems were in place to ensure that important information is conveyed to healthcare professionals. Evidence does not suggest that this communications failure contributed to Sylvia’s death. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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

Require staff to contact appropriate medical professionals, pass observations for clinical advice, and document and follow the advice after a fall.

Verbatim wording from the response

“In response to your report in relation to S Gibson, dated the 27/10/2022, the following actions have been implemented with immediate effect:”

Source location

Response from Lambton House
Page 1 · response
Published 31 October 2022

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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.5

  1. 1

    Provide all senior staff with supervision on the importance of communication and documentation.

    Stated by Lambton HouseStated plannedThe respondent said that this action was planned when they made their response on 31 October 2022.
  2. 2

    Require the senior care manager on duty to visually check the service user after a fall.

    Stated by Lambton HouseStated completedThe respondent said that this action was complete when they made their response on 31 October 2022.
  3. 3

    Distribute the fall-response actions to all senior staff.

    Stated by Lambton HouseStated completedThe respondent said that this action was complete when they made their response on 31 October 2022.
  4. 4

    Require completion and recording of oxygen saturation, pulse, blood pressure, temperature and respiratory-rate observations after a fall.

    Stated by Lambton HouseStated completedThe respondent said that this action was complete when they made their response on 31 October 2022.
  5. 5

    Require full documentation of every witnessed or unwitnessed fall.

    Stated by Lambton HouseStated completedThe respondent said that this action was complete when they made their response on 31 October 2022.

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

Provide all senior staff with supervision on the importance of communication and documentation.

Verbatim wording from the response

“The above actions must be followed in the event of any fall. All senior members of staff will receive a supervision on the importance of communication and documentation. They have also received a copy of the above actions.”

Source location

Response from Lambton House
Page 1 · response
Published 31 October 2022

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

Require the senior care manager on duty to visually check the service user after a fall.

Verbatim wording from the response

“In response to your report in relation to S Gibson, dated the 27/10/2022, the following actions have been implemented with immediate effect:”

Source location

Response from Lambton House
Page 1 · response
Published 31 October 2022

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

Distribute the fall-response actions to all senior staff.

Verbatim wording from the response

“The above actions must be followed in the event of any fall. All senior members of staff will receive a supervision on the importance of communication and documentation. They have also received a copy of the above actions.”

Source location

Response from Lambton House
Page 1 · response
Published 31 October 2022

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

Require completion and recording of oxygen saturation, pulse, blood pressure, temperature and respiratory-rate observations after a fall.

Verbatim wording from the response

“In response to your report in relation to S Gibson, dated the 27/10/2022, the following actions have been implemented with immediate effect:”

Source location

Response from Lambton House
Page 1 · response
Published 31 October 2022

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

Require full documentation of every witnessed or unwitnessed fall.

Verbatim wording from the response

“In response to your report in relation to S Gibson, dated the 27/10/2022, the following actions have been implemented with immediate effect:”

Source location

Response from Lambton House
Page 1 · response
Published 31 October 2022

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