PFD report

Elizabeth PAMMENT · Prevention of Future Deaths report

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Issued 8 Jan 2021•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.

View original report
Concerns
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised3

  1. Failure to communicate and record emergency contact instructions for alarm monitoring staff
  2. Failure to review and improve emergency procedures after a serious incident
    Part of recurring concern: Failure to learn from deaths through systematic review
  3. Failure to obtain and record personalised emergency contact instructions
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.3

  1. Action

    Amend Careline information sharing and produce a standard Resident Information Form capturing consent, special instructions and emergency next-of-kin arrangements.

    Stated by Peabody TrustStated completedThe respondent said that this action was complete when they made their response on 14 January 2021.
  2. Action

    Meet Islington Telecare and other Careline providers to review and standardise information forms and procedures, incorporating learning from the incident.

    Stated by Peabody TrustStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.
  3. Action

    Implement a procedure to ask residents about contact instructions, review existing records, and log and share special arrangements with relevant Careline providers.

    Stated by Peabody TrustStated plannedThe respondent said that this action was planned when they made their response on 14 January 2021.

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

  1. Position

    The prior review identified no specific procedural or staff failings, and family concerns were not known until the inquest.

    Stated by Peabody TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 communicate and record emergency contact instructions for alarm monitoring staff

Wider context from the report

“When Elizabeth Pamment moved in to Alleyn House in 2016, she and her family gave explicit instructions that, in the event of any emergency, her daughter living very nearby was to be contacted. This was discussed in some detail and agreed to by Peabody staff. Mrs Pamment wore a pendant to enable her to summon assistance in the event of a fall or other emergency. She used this for the first time on the evening of 12 August 2020. Staff from Islington Telecare attended and helped her back to bed. However, they were unaware of the standing instruction to call her daughter and so did not do this. The consequence of this was that, when Mrs Pamment fell again the same night and was unable to get up or call for help, she had to spend the night alone on the floor getting more and more unwell. Peabody staff explained the following in evidence. 1. There was no record made by Peabody of the instruction given by Mrs Pamment and her family. 2. There was no Peabody protocol for the taking and recording such an instruction. 3. The Peabody scheme manager checked personal details with tenants from time to time, but was never advised to obtain such an instruction regarding when to call a family member. 4. Peabody gave tenants’ personal details to Islington Telecare, but kept no record of what information they had passed on to the alarm monitoring company. Witnesses in court had no idea what Islington Telecare had been told to do in the event of an emergency with Mrs Pamment. 5. Despite Mrs Pamment’s death occurring in August 2020, it was not until today at inquest that Peabody staff considered making any changes to their procedures. If Islington Telecare had been instructed always to contact Mrs Pamment’s daughter in the event of an emergency, ████████ would have been rung as soon as the team had been sent out to Elizabeth Pamment, and in fact would have arrived before them. She would then have stayed and looked after her mum. It is unclear whether that would have saved Mrs Pamment’s life but it is possible, and it certainly would have significantly improved her physical and emotional comfort. ”

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 to review and improve emergency procedures after a serious incident

Wider context from the report

“When Elizabeth Pamment moved in to Alleyn House in 2016, she and her family gave explicit instructions that, in the event of any emergency, her daughter living very nearby was to be contacted. This was discussed in some detail and agreed to by Peabody staff. Mrs Pamment wore a pendant to enable her to summon assistance in the event of a fall or other emergency. She used this for the first time on the evening of 12 August 2020. Staff from Islington Telecare attended and helped her back to bed. However, they were unaware of the standing instruction to call her daughter and so did not do this. The consequence of this was that, when Mrs Pamment fell again the same night and was unable to get up or call for help, she had to spend the night alone on the floor getting more and more unwell. Peabody staff explained the following in evidence. 1. There was no record made by Peabody of the instruction given by Mrs Pamment and her family. 2. There was no Peabody protocol for the taking and recording such an instruction. 3. The Peabody scheme manager checked personal details with tenants from time to time, but was never advised to obtain such an instruction regarding when to call a family member. 4. Peabody gave tenants’ personal details to Islington Telecare, but kept no record of what information they had passed on to the alarm monitoring company. Witnesses in court had no idea what Islington Telecare had been told to do in the event of an emergency with Mrs Pamment. 5. Despite Mrs Pamment’s death occurring in August 2020, it was not until today at inquest that Peabody staff considered making any changes to their procedures. If Islington Telecare had been instructed always to contact Mrs Pamment’s daughter in the event of an emergency, ████████ would have been rung as soon as the team had been sent out to Elizabeth Pamment, and in fact would have arrived before them. She would then have stayed and looked after her mum. It is unclear whether that would have saved Mrs Pamment’s life but it is possible, and it certainly would have significantly improved her physical and emotional comfort. ”

Is this part of a recurring concern?

Yes — Failure to learn from deaths through systematic review.

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 and record personalised emergency contact instructions

Wider context from the report

“When Elizabeth Pamment moved in to Alleyn House in 2016, she and her family gave explicit instructions that, in the event of any emergency, her daughter living very nearby was to be contacted. This was discussed in some detail and agreed to by Peabody staff. Mrs Pamment wore a pendant to enable her to summon assistance in the event of a fall or other emergency. She used this for the first time on the evening of 12 August 2020. Staff from Islington Telecare attended and helped her back to bed. However, they were unaware of the standing instruction to call her daughter and so did not do this. The consequence of this was that, when Mrs Pamment fell again the same night and was unable to get up or call for help, she had to spend the night alone on the floor getting more and more unwell. Peabody staff explained the following in evidence. 1. There was no record made by Peabody of the instruction given by Mrs Pamment and her family. 2. There was no Peabody protocol for the taking and recording such an instruction. 3. The Peabody scheme manager checked personal details with tenants from time to time, but was never advised to obtain such an instruction regarding when to call a family member. 4. Peabody gave tenants’ personal details to Islington Telecare, but kept no record of what information they had passed on to the alarm monitoring company. Witnesses in court had no idea what Islington Telecare had been told to do in the event of an emergency with Mrs Pamment. 5. Despite Mrs Pamment’s death occurring in August 2020, it was not until today at inquest that Peabody staff considered making any changes to their procedures. If Islington Telecare had been instructed always to contact Mrs Pamment’s daughter in the event of an emergency, ████████ would have been rung as soon as the team had been sent out to Elizabeth Pamment, and in fact would have arrived before them. She would then have stayed and looked after her mum. It is unclear whether that would have saved Mrs Pamment’s life but it is possible, and it certainly would have significantly improved her physical and emotional comfort. ”

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

Amend Careline information sharing and produce a standard Resident Information Form capturing consent, special instructions and emergency next-of-kin arrangements.

Verbatim wording from the response

“In order to address the concern raised, we have amended how we share residents’ information with Islington Telecare to ensure that any specific requests are captured with the resident’s permission and noted to the Careline provider. We have also included a section that explains to the resident that if the resident is alerted out of hours and the call requires an emergency response then the Careline provider will always contact their NOK unless the resident specifically opts out of that procedure.”

Source location

2021-0006-Response-from-Peabody-Redacted
Page 3 · response
Published 14 January 2021

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

Meet Islington Telecare and other Careline providers to review and standardise information forms and procedures, incorporating learning from the incident.

Verbatim wording from the response

“Our service manager has made arrangements to meet all other careline providers we commission to review the other forms in use to see if they could be improved. The outcome of those discussions will further inform our procedural review.”

Source location

2021-0006-Response-from-Peabody-Redacted
Page 3 · response
Published 14 January 2021

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

Implement a procedure to ask residents about contact instructions, review existing records, and log and share special arrangements with relevant Careline providers.

Verbatim wording from the response

“As per the previous action above, we will now always use a comprehensive form to exchange essential information with Careline providers and this will include any special instructions from the resident.”

Source location

2021-0006-Response-from-Peabody-Redacted
Page 4 · response
Published 14 January 2021

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

The prior review identified no specific procedural or staff failings, and family concerns were not known until the inquest.

Verbatim wording from the response

“We were not aware of the concerns raised by the family until our attendance at the inquest and our own review had not identified any specific procedural or staff failings. Previous incidents had also not highlighted gaps in our practice.”

Source location

2021-0006-Response-from-Peabody-Redacted
Page 5 · response
Published 14 January 2021

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

    Implement senior management oversight for staff involvement in future inquests.

    Stated by Peabody TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 January 2021.
  2. 2

    Install key safes for flats across Older People’s Social Housing services to support emergency access.

    Stated by Peabody TrustStated in progressThe respondent said that this action was in progress when they made their response on 14 January 2021.

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

  1. 1

    An existing protocol required recording essential resident information in Peabody’s case management system.

    Stated by Peabody TrustDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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

Implement senior management oversight for staff involvement in future inquests.

Verbatim wording from the response

“In terms of the inquest proceedings, it is also recognised that the witnesses from Peabody were not appropriately supported when responding to and attending the inquest. Therefore Peabody is also implementing a new process whereby there is appropriate senior management oversight for involvement of Peabody’s staff in any future inquests.”

Source location

2021-0006-Response-from-Peabody-Redacted
Page 5 · response
Published 14 January 2021

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

Install key safes for flats across Older People’s Social Housing services to support emergency access.

Verbatim wording from the response

“• As part of wider work and part of a review of Careline service, we are installing key safes for each flat within Peabody’s Older Peoples’ Social Housing services to assist with access for emergency services or appropriate persons.”

Source location

2021-0006-Response-from-Peabody-Redacted
Page 5 · response
Published 14 January 2021

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

An existing protocol required recording essential resident information in Peabody’s case management system.

Verbatim wording from the response

“It is Peabody’s protocol to record essential information about the resident within our case management system. All residents are assessed as part of the moving in process and there is a continuous process of review throughout their tenure. Information captured includes relevant history, additional needs, next of kin details and other essential information such as medical information.”

Source location

2021-0006-Response-from-Peabody-Redacted
Page 4 · response
Published 14 January 2021

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