PFD report

May Hall · Prevention of Future Deaths report

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Issued 3 Sep 2015•Manchester 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.

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Concerns
5

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

Select any concern, action or position to view the source wording.

Concerns raised5

  1. Failure to regularly review fall-response training
    Part of recurring concern: Unreliable post-fall assessment and clinical response
  2. Lack of staff awareness of the policy for calling the ambulance or emergency doctor after a fall
  3. Lack of clear staff training on addressing falls
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

Failure to regularly review fall-response training

Wider context from the report

“The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”

Is this part of a recurring concern?

Yes — Unreliable post-fall assessment and clinical response.

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

Lack of staff awareness of the policy for calling the ambulance or emergency doctor after a fall

Wider context from the report

“The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Lack of clear staff training on addressing falls

Wider context from the report

“The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Lack of staff awareness of the policy for reporting falls

Wider context from the report

“The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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 obtain staff confirmation of receipt of fall-response training

Wider context from the report

“The Bourne House staff indicated that they were not aware of a policy for reporting falls and for calling the ambulance or emergency doctor. There should be clear training as to how any fall should be addressed by the staff and they should sign to confirm that they have received such training which should be regularly reviewed. ”

Is this part of a recurring concern?

Yes — Inadequate control of falls risks.

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