PFD report

Margaret Jane METCALFE · Prevention of Future Deaths report

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Issued 14 Mar 2016•Teesside

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
2

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
11

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. Failure of bed alarms to alert staff when a person gets out of bed
  2. Failure of the hand-held buzzer to alert staff
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.9

  1. Action

    Check all four Care Assist pagers and their charging units.

    Stated by Stockton-on-Tees Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 March 2016.
  2. Action

    Require timely responses to Care Assist alerts and immediate documented escalation of pager problems to the Duty Manager.

    Stated by Stockton-on-Tees Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 March 2016.
  3. Action

    Move Care Assist charging units to the main office for management oversight.

    Stated by Stockton-on-Tees Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 March 2016.

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 of bed alarms to alert staff when a person gets out of bed

Wider context from the report

“Mrs Metcalfe had requested help from staff by pressing a hand held buzzer. Her bed had been fitted with a specialist alarm that should have alerted staff that she had got up out of bed. For unknown reasons staff were not alerted by either the hand held buzzer or bed alarms but instead were alerted by hearing a “thud” in the corridor when Mrs Metcalfe fell. ”

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

Failure of the hand-held buzzer to alert staff

Wider context from the report

“Mrs Metcalfe had requested help from staff by pressing a hand held buzzer. Her bed had been fitted with a specialist alarm that should have alerted staff that she had got up out of bed. For unknown reasons staff were not alerted by either the hand held buzzer or bed alarms but instead were alerted by hearing a “thud” in the corridor when Mrs Metcalfe fell. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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

Check all four Care Assist pagers and their charging units.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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 timely responses to Care Assist alerts and immediate documented escalation of pager problems to the Duty Manager.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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

Move Care Assist charging units to the main office for management oversight.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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

Remind Unit Managers of the Care Assist procedure and require discussion with team members.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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

Risk-assess each person through the Therapy Team to identify Care Assist allocations.

Verbatim wording from the response

“5. Each person will be risk assessed by the Therapy Team to identify who will be allocated a Care Assist unit.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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

Audit Care Assist equipment monthly through the Manager's audit process.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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

Relabel each Care Assist pager to identify its allocated unit and charging system.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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 allocated staff to recharge, carry, hand over and check Care Assist pagers, recording relevant checks in care records.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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

Check Care Assist bedroom allocations and pager responsibility at every shift handover.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

Open published response

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.2

  1. 1

    Document Care Assist use in each person's Care Plan and Kardex record.

    Stated by Stockton-on-Tees Borough CouncilStated completedThe respondent said that this action was complete when they made their response on 14 March 2016.
  2. 2

    Remind staff to remain vigilant and give interim fall-risk instructions until Care Assist equipment is fitted.

    Stated by Stockton-on-Tees Borough CouncilStated plannedThe respondent said that this action was planned when they made their response on 14 March 2016.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.1

  1. 1

    Care Assist equipment cannot guarantee immediate staff action because staff may be occupied assisting other residents.

    Stated by Stockton-on-Tees Borough CouncilUnable to actThe respondent said that a constraint prevented them from taking the relevant action.

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

Document Care Assist use in each person's Care Plan and Kardex record.

Verbatim wording from the response

“Subsequent Actions Taken In response to your request that action be taken to prevent future deaths from falls the following actions have been taken and a written procedure implemented.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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

Remind staff to remain vigilant and give interim fall-risk instructions until Care Assist equipment is fitted.

Verbatim wording from the response

“6. Staff will be reminded by the Therapy Team of the need to be extra vigilant and give special instructions to minimise risks until Care Assist equipment is fitted.”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

Open published response

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

Care Assist equipment cannot guarantee immediate staff action because staff may be occupied assisting other residents.

Verbatim wording from the response

“Clearly steps are being taken by the Rosedale Centre to use available technology to assist staff in receiving timely information as to the movements of people identified to be at risk. The equipment being used is not something that can guarantee immediate action by the staff even when alerts are notified. Staff on duty have a responsibility for all people on the unit they are allocated. Generally staff are supporting people with a full range of daily personal care tasks and can be called upon at”

Source location

2016-0107-Response-by-Stockton-on-Tees-Borough-Council
Page 4 · response
Published 14 March 2016

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