Care risk assessment failures
163 items
2 sources
Ineffective assessment, monitoring, and mitigation of health, safety, and welfare risks for individuals receiving personal care.
Cross-Source Insight
Care risk assessment failures has been flagged across 2 independent accountability sources:
14 inquiry recs
149 PFD reports
This issue has been identified by multiple independent accountability bodies, suggesting it is a recurring systemic concern.
Inquiry Recommendations (14)
JB-15.2 — Require multidimensional risk assessments throughout operations
Recommendation: Training should emphasise that multidimensional risk assessments must be carried out throughout police operations, including the planning and briefing of operations. Those risk assessments should assess the future threat and risk at all stages of the operation.
Gov response: MPS formally responded on 28 October 2022 (paras 7-8). Firearms trainers required to watch Inquiry hearing recordings. Particular focus now on multidimensionality at all stages of operational planning. MO19 supporting College of Policing on improved …
Accepted
Delivered
JB-15.4 — Amend firearms authorisation forms for risk assessment and tipping points
Recommendation: There should be an amendment to FA (and equivalent) forms to: a. encourage a multidimensional risk assessment (to comply with Article 2) to minimise, to the greatest extent possible, recourse to lethal force; b. include a provision for reference to …
Gov response: No formal NPCC response published. MPS response (28 October 2022, paras 12-14) confirms NPCC project reviewing FA form amendments nationally. MPS issued internal guidance to CTSFO Tac Advisors within MO19 pending national outcomes.
Accepted
Delivered
6 — Draw up maternity risk assessment protocol
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should draw up a protocol for risk assessment in maternity services, setting out clearly: who should be offered the option of delivery at Furness General Hospital and who should not; who …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
7 — Audit maternity and paediatric services
Recommendation: The University Hospitals of Morecambe Bay NHS Foundation Trust should audit the operation of maternity and paediatric services, to ensure that they follow risk assessment protocols on place of delivery, transfers and management of care, and that effective multidisciplinary care …
Gov response: [A] Recommendations for the Trust Recommendations for the Trust: 1-18 1. The Morecambe Bay Investigation found that there were serious failures in clinical care at University Hospitals Morecambe Bay NHS Foundation Trust, causing avoidable harm …
Accepted
WATE-(31) — Require comprehensive child needs assessment before admission to care
Recommendation: Whenever it is possible to do so, an appropriate social worker should carry out a comprehensive assessment of a child's needs and family situation before that child is admitted to care.
Unknown
WATE-(32) — Follow emergency child admissions with comprehensive assessment within prescribed period
Recommendation: All emergency admissions should be provisional and should be followed, within a prescribed short period, by a comprehensive assessment of the child's needs and family situation.
Unknown
WATE-(33) — Base care plans on comprehensive assessment, prepared with child consultation
Recommendation: The comprehensive assessment referred to in recommendations (31) and (32) should form the basis for the preparation of a care plan in consultation with and for the child within a prescribed short period after the child's admission to care.
Unknown
WATE-(45) — Require social worker assessment and inter-departmental consultation before residential school placement
Recommendation: Any placement of a child by a local education department or by a social services department in a residential school should be preceded by: (a) consultation between the departments as to whether an assessment by an appropriate social worker of …
Unknown
WATE-(46) — Prohibit emergency admissions to all private residential schools
Recommendation: Emergency admissions should not be made to private residential schools.
Unknown
POH-12 — Amend GLOS to allow claimants oral submissions at panel hearings
Recommendation: The scheme documents governing GLOS should be amended so that a right is conferred upon claimants (exercisable by the claimants themselves or their recognised legal representatives) to make oral submissions in support of their claim at the hearing convened by …
Gov response: Department for Business and Trade accepts this recommendation. GLOS claimants already had the right to make oral submissions for up to one hour at independent panel hearings prior to the panel making a binding determination. …
Accepted
Delivered
POH-14 — Post Office to engage in negotiations during HSSA appeal period
Recommendation: During the nine-month period afforded to claimants to submit an appeal to the Department in HSSA, the Post Office shall engage in negotiations and/or mediation with any claimants who notify the Post Office of a desire to seek a negotiated …
Gov response: Department for Business and Trade accepts this recommendation. Rather than a 9-month period, DBT has implemented a 3-month notification deadline for claimants to indicate their intent to appeal, with subsequent deadlines for submission of full …
Accepted
Delivered
R25 — Pressure damage risk assessment
Recommendation: Health Boards should ensure that every patient is assessed for risk of pressure damage on admission to hospital using a recognised tool such as the Waterlow Score.
Gov response: Section 4.1 of the Scottish Government's response addresses this by stating that the prevention and management of pressure ulcers is a fundamental aspect of nursing practice. Healthcare Improvement Scotland published a Best Practice Statement - …
Accepted
R28 — Nutritional screening
Recommendation: Health Boards should ensure that all patients have their nutritional status screened on admission to a ward using a recognised nutritional screening tool.
Gov response: Section 4.1 of the Scottish Government's response acknowledges the report's criticisms of specific elements of nursing care, including the unsatisfactory assessment and recording of patients' nutritional status. The government unreservedly accepts in full the report's …
Accepted
R7 — Reorganisation due diligence
Recommendation: In any major structural reorganisation in the NHS in Scotland a due diligence process including risk assessment, should be undertaken by the Board or Boards responsible.
Gov response: Section 2.2 of the Scottish Government's response describes the 'Governance for Quality Healthcare in Scotland - an Agreement' and a 'clinical and care governance framework for integrated health and social care services' to ensure good …
Accepted
PFD Reports (149) — showing 100 most recent
George Ritchie
Concerns: The nursing home had inadequate falls risk assessments and care plans, lacking oversight and supervision. Additionally, low night-time staffing was not addressed, risking residents in this and other facilities.
Responded
Debapriya Ghosh and David Ward
Concerns: Insufficient staffing and bed spaces in A&E resulted in frail elderly patients being unsupervised, leading to unwitnessed falls, fatal head injuries, and a failure to provide necessary enhanced nursing care.
Response: The Department for Health and Social Care acknowledges A&E staffing and demand concerns, highlighting actions already implemented by St George’s Trust. DHSC's own response outlines a 2025/26 Urgent and Emergency …
Responded
Celia Phillips
Concerns: Carers for a bed-bound patient lacked understanding and training in preventing pressure sores, failing to perform crucial repositioning or properly assess skin, despite documented need.
Response: Inspire You Care Ltd has updated all service user care plans to include repositioning instructions and information from other professionals, and trained staff to understand and follow these plans. Refresher …
Responded
Brian Lloyd
Concerns: Patients with two failed catheter insertion attempts are not being transferred to hospital promptly, creating a risk of delay in necessary medical intervention.
Response: High Meadows Care Home has updated its catheterisation policy, created and disseminated a new Catheter Emergency and Escalation Protocol, and provided staff training. They also reconfigured their telephone system and …
Response: High Meadows Care Home has implemented an 'Escalation Protocol for Team Leads' (Version 1.0, implemented 23/10/2025) outlining how staff must recognise, respond to, and promptly escalate clinical concerns, specifically referencing …
Responded
Rashida Sultana
Concerns: Nursing staff lacked clarity on when to call the Emergency Medical Response Team for patients with a DNAR. There was also an absence of risk assessments for Speech and Language Therapy referrals for dysphagia.
Response: The organisation has approved and implemented an updated 'Emergency Medical Response Policy including Management of Resuscitation' in March 2025, which outlines systems, processes, and structures for safe and effective care …
Responded
Marcia Grant
Concerns: A shortage of foster placements, combined with inadequate documentation, poor communication of risks, and a failure to assess risks to carers, led to an unsuitable child placement.
Overdue
Edwin Price
Concerns: A falls risk assessment was not completed within the required timeframe, failing to identify specific risks and implement mitigation measures, and no subsequent actions were taken to address these systemic gaps.
Responded
Stephen Lawrence
Concerns: A resident sustained unexplained injuries, followed by deficient record-keeping, delayed medical advice after a fall, and conflicting evidence from the nursing home manager, indicating an ongoing risk to residents.
Responded
Margaret Medlicott
Concerns: A care home admitted a resident with a history of aggression against policy, without proper clinical assessment. Staff lacked empowerment to challenge this decision and were inadequately trained in risk assessments and care plan creation.
Responded
Melissa Mathieson
Concerns: The care home provided misleading information on supervision levels and lacked formal induction periods, regular reviews for residents, and comprehensive updates to support plans and risk assessments.
Responded
Patricia Heaviside
Concerns: The care home failed to implement recommended falls prevention equipment due to resource reluctance, didn't share critical information, and neglected to apply for Deprivation of Liberty Safeguards (DoLS) assessments for residents lacking mental capacity.
Overdue
Margaret Douglas
Concerns: The care home accepted a patient despite being unable to meet her complex one-to-one care needs, and outsourced carers lacked adequate communication skills and understanding of patient requirements.
Overdue
Sonia Sore
Concerns: The care home demonstrated a cultural problem of inadequate risk assessment and mitigation, with staff consistently failing to implement identified safety measures like securing bed rails.
Responded
Anthony Wood
Concerns: A high-risk, severely frail patient fell due to inadequate falls prevention, including missing crash mats, a lowered bed-rail, and only one staff member attending when two were required.
Overdue
George Fraser
Concerns: The Mental Health and Wellness Team failed to establish a clear care plan or robust risk assessment. They also neglected to act on concerns about patient contact, delaying risk review and family notification.
Responded
Peter Good
Concerns: Indications of prolonged neglect, including poor hygiene and infected wounds, prompted a safeguarding alert. However, the nursing home owner failed to investigate this to identify learning or assess ongoing risks to other residents.
Responded
Jean Mullen
Concerns: Social care dismissed family concerns regarding the deceased's ability to manage stairs and live safely at home post-fall, relying on an inadequate assessment despite clear evidence of deteriorating capacity.
Responded
Colin Wiles
Concerns: A Vulnerable Adult Risk Management meeting was not held despite high risks. Callers are not clearly advised to re-contact emergency services if concerns persist, and excessive ambulance handover delays significantly impact emergency care.
Responded
Janet Brown Townend
Concerns: Carers provided insufficient care time and failed to escalate critical concerns regarding the patient's deteriorating health, including inaccurate EWS recording and neglect to reassess capacity for unwise decisions.
Overdue
Christiana Dawson
Concerns: Agency nurses were not provided with essential care home-specific training or policies, leading to an unsafe presumption they would know not to move a resident after a fall.
Responded
Robin van Caliskan
Concerns: A company's risk assessment dismissed lifeguards as impractical, yet a safety officer found compliance borderline and noted other similar venues employed them. Concerns exist that lessons about pool safety and the necessity of lifeguards have not been learned.
Responded
Malika Hibu
Concerns: Peabody Housing Association failed to address an unsafe canal barrier, demonstrating a lack of boundary knowledge, neglected risk assessments, ignored resident complaints, and inaction on known safety hazards.
Overdue
Maureen Woollen
Concerns: The care home failed to conduct a falls risk assessment on admission and did not promptly seek medical attention for injuries. Care notes were inadequately used to record incidents or monitor injury progression.
Responded
Christopher Larsen
Concerns: Mental health MDT meetings suffered from poor attendance by those familiar with the patient and inadequate documentation of risk assessment decisions, while a nurse failed to review medical records.
Responded
Neville Abbott
Concerns: A critical "Professionals Checklist" for identifying self-neglect risks, including declining medication, was not used by adult social care practitioners, leading to missed multi-agency risk management opportunities.
Responded
Angela Carpos
Concerns: Care home staff lacked adequate training and awareness to recognise aspiration pneumonia, and the company's training quality and policy knowledge were insufficient.
Responded
Michael Burke
Concerns: Inadequate systems meant falls risk assessments were not completed or handed over during ward transfers, failing to manage patient fall risks effectively.
Responded
Christopher Townsend
Concerns: The ACU's generic, pre-populated risk assessment for grass-track events and the lack of a mandatory event-specific safety plan for Club/National events create a significant risk of future deaths.
Responded
Saffra Winn
Concerns: Sheffield City Council failed to conduct risk assessments for high-rise windows after two fatalities and lacks formal procedures for investigating and assessing risks following catastrophic incidents in social housing.
Responded
Michaela Hall
Concerns: Children and Adult Services failed to consider the family as a whole, lacked written rationale for care needs and safeguarding decisions, and neglected health-related enquiries despite signs of mental impairment.
Responded
Regina Ademiluyi
Concerns: Deficiencies in safeguarding reporting, failure to assess mental capacity, and lack of a carer assessment led to Regina being deprived of entitled domiciliary care. Little meaningful reflection or remediation followed her death.
Responded
Sydney Piper
Concerns: Inadequate supervision of a vulnerable person by an untrained support worker and insufficient monitoring of high-risk homeless encampments both present ongoing risks of fatal harm.
Responded
Sarah Sutherland
Concerns: A private psychotherapist failed to keep clinical records, conduct risk assessments for EUPD, provide evidence of treatment analysis or review, maintain professional boundaries, or communicate with NHS mental health services.
Overdue
Sylvia White
Concerns: Inadequate hospital discharge summaries consistently lack crucial patient information, preventing care homes from conducting proper risk assessments and ensuring safe ongoing care.
Responded
Jeanine Huggins
Concerns: Hospitals lack formal risk assessments for patients in side rooms, failing to identify communication difficulties or call bell usage ability, hindering emergency alerts.
Responded
Nadia Wyatt
Concerns: Failures in care planning included incomplete patient records, lack of bespoke care plans with "cutting and pasting," inadequate risk assessments, and an over-reliance on the patient's carer.
Responded
Andrew Rees
Concerns: A broken marina rescue chain was missed by visual inspections, and the council lacked formal assessment to trigger reviews of port risk assessments based on changes in usage.
Responded
Julia Murphy
Concerns: The care home failed to implement comprehensive falls prevention, with inaccurate reporting, poor escalation for frequent falls, and insufficient staff training and risk assessment for a resident with evolving dementia.
Overdue
Ann Pearce
Concerns: The Venous Thromboembolism Prevention Policy lacked provisions for risk assessment in patients attending hospital but not admitted, leaving a critical gap in VTE prevention.
Responded
Margaret Austin
Concerns: The care home exhibited inadequate falls risk management with inconsistent documentation, no plan reviews for changing risks, and a majority of staff lacking essential falls training.
Responded
Luke Whitelaw
Concerns: Missed opportunities for urgent psychiatric review and readmission occurred, alongside a lack of "professional curiosity," poor documentation, and inadequate risk assessment formulation in patient care.
Responded
Raymond Eggleton
Concerns: Inadequate initial falls risk assessment and lack of dynamic staffing resilience, particularly during night shifts, led to insufficient supervision and preventable falls for vulnerable elderly patients in the hospital.
Responded
Ocean-Leigh Hayes
Concerns: Health visitors are inconsistently conducting physical reviews of sleeping arrangements for babies, missing opportunities to risk assess co-sleeping environments and advise parents on dangers.
Responded
Owen Garnett
Concerns: A school failed to act on carers' concerns and provided inadequate supervision, allowing a child to consume harmful materials. Staff lacked clear guidance on identifying and escalating health and safety issues.
Overdue
Iain Farrell
Concerns: Concerns arise from risks associated with lone guiding in coasteering, including guide incapacitation, delayed alarm raising due to inaccessible communication, and inadequate assessment of participant swimming ability or fitness.
Responded
Sandra Curran
Concerns: UK tour operators failed to adequately warn holidaymakers, particularly weak swimmers, about the risks and challenges of sea swimming and snorkelling in unfamiliar locations with strong currents.
Responded
Kellie Poole
Concerns: There is a significant lack of regulatory oversight and clear safety guidance for cold water immersion businesses, leading to inadequate risk assessments, inconsistent leader training, and insufficient safety measures for participants.
Responded
Paula Lenihan
Concerns: The Trust has a systemic failure in completing and updating patient risk assessments, risking future deaths. A task group addressing this issue is in its early stages, providing no immediate resolution.
Responded
John Wrigley
Concerns: The tyre barrier failed to absorb sufficient impact energy, and available energy-dissipating protection was not utilised. Furthermore, wet track conditions and racer error were not adequately considered in safety assessments.
Responded
Anthony Friend
Concerns: A complete lack of handover and communication between transferring care agencies meant the new provider was unaware of patient needs and critical equipment concerns.
Responded
Amarjit Singh
Concerns: There was a careless cell sharing risk assessment, inadequate first aid training for prison officers, and no guidance for prisoners on how to respond to a cellmate having a fit.
Responded
Donna Levy
Concerns: Domiciliary care failed to address severe self-neglect, with no formal Mental Capacity Act assessment or mental health referral despite obvious deterioration. The Trust's flawed investigation decision overlooked wider health problems.
Responded
Jacqueline Smith
Concerns: Inadequate staff training for complex hoarding cases, failure to conduct necessary safety assessments, and a flawed council support process focused on enforcement, left a vulnerable tenant without effective assistance.
Overdue
Doris Urch
Concerns: The care home's risk assessment process was inadequate, lacking specific recommendations and not updated after falls. Staff were unfamiliar with care plans, and the system failed to preserve historical records.
Responded
Kenneth Rippon
Concerns: Extensive delays in serious incident investigations (10 months instead of 60 days) prevented timely learning and improvements, compromising investigation quality and evidence preservation.
Responded
Elsie Leaver
Concerns: Critical failures included not recognising the patient's extensive psychiatric history and suicidality, inadequate risk assessments, and lack of bag searches during hospital transfers, contributing to her death by overdose.
Overdue
Bridget Gormley
Concerns: Care home staff failed to update falls risk assessments and care plans after multiple incidents, preventing awareness of increased risk and implementation of critical mitigation measures.
Overdue
Hazel Mayho
Concerns: Frail, dementia patients at high risk of falls have unsupervised access to hazardous gardens due to open doors and distracted staff. The care home lacks effective exit control or alert systems to prevent vulnerable residents from entering alone.
Responded
Lilian Shearing
Concerns: Despite known poor fluid intake, no risk assessment was conducted, and fluid charts were incomplete. The care home lacked adequate policies for assessing and managing fluid and nutritional intake.
Responded
Gerald Tuck
Concerns: The care home lacked a formal policy or guidance for reviewing care plans and risk assessments following incidents like falls. This systemic gap led to a crucial falls risk assessment not being updated after multiple falls, increasing future risk.
Responded
Marvin Rue
Concerns: Repeated failures to conduct Multifactorial Risk Assessments for a known falls risk patient, despite multiple falls and transfers, were not addressed by previous action plans or staff accountability.
Overdue
Reginald Weston
Concerns: The care home lacked documented reviews of residents' falls risk assessments following incidents and needed a more timely process for completing these critical safety evaluations.
Responded
Dilys Etchells
Concerns: The care home showed inadequate provision and documentation of safety equipment, poor note-taking, insufficient staff training in visual checks and handover, and deficient wound management protocols.
Responded
David O’Brien
Concerns: Poor record-keeping and inter-agency communication in the care home resulted in critical wheelchair safety advice being ignored, leading to the deceased's excessive and unsafe use of the mobility aid.
Overdue
Rebecca Begg
Concerns: The care home failed to monitor care plan compliance, conducted inadequate incident reviews, and lacked inclusion of support workers in client meetings, with no dedicated time for staff to read care plans.
Overdue
Lorraine Karat
Concerns: Lack of a risk assessment for an unsafe, accessible balcony, inadequate communication regarding its use, and absence of safety barriers or window restrictors created a significant fall risk in housing properties.
Responded
Henry Doll
Concerns: Care home management demonstrated a significant misunderstanding of risk assessment processes, leading to inaccurate choking risk identification for residents, and staff provided ineffective CPR.
Overdue
Angela Best
Concerns: A high-risk individual's critical discharge condition, requiring disclosure of intimate relationships, relied solely on his self-reporting despite known untruthfulness, with no independent verification mechanism.
Responded
Catherine Jux
Concerns: A nursing home failed to complete a patient risk assessment within 24 hours of admission due to oversight, which staff did not notice, indicating an inadequate auditing process.
Overdue
Liam Kenyon
Concerns: Supported housing showed a lack of clarity in their duty of care, failed to conduct agreed hourly checks, and did not follow procedures for drug checks or risk assessment updates. Welfare checks were inadequate due to staff shortages and poor escalation.
Overdue
Valeria Biggs
Concerns: Failures in mental health care included serious underestimation of suicidality, delayed psychiatric assessment, and inadequate medication. The Home Treatment Team failed to visit and assess risk despite police warnings and neglected family concerns.
Overdue
Jean Williams
Concerns: Bed levers are improperly fitted by untrained staff without patient assessment, and policy gaps hinder reporting concerns. Miscommunication prevents trained professionals from fitting them, and there is a risk of supplying levers without essential safety straps for Divan beds.
Responded
Barry Preston
Concerns: Poor documentation, unsuitable ward placements due to capacity issues, and a lack of care coordination between agencies impacted patient safety. Additionally, the patient's capacity was misunderstood, and an unsuitable placement led to falls and injury.
Responded
Mary Brady
Concerns: Open waste paper baskets in communal areas posed a choking hazard, exacerbated by improper disposal of clinical waste. Staff also failed to document or risk-assess a resident's habit of ingesting non-food items, leading to an incomplete understanding of risk.
Responded
John Ashley
Concerns: Critical failures include outdated care plans, poor record-keeping and information compilation, lack of psychiatrist reviews, inconsistent risk assessment policies, and inadequate handover procedures, all contributing to a fragmented care system.
Overdue
Benjamin Leonard
Concerns: The Scout Association failed to implement or ensure understanding of critical safety policies, including risk assessments and leadership oversight, for an organised trip, directly endangering young people.
Responded
Iris Skinner
Concerns: Agency staff employed by the care home, and potentially across the healthcare group, may be unfamiliar with the critical Head Injury Policy, unlike permanent staff.
Responded
Andrew Hogg
Concerns: A care home failed to adequately assess and manage escalating falls risks, lacking a comprehensive falls policy, proper risk reassessments, internal investigations, and proactive measures or equipment to prevent repeated incidents.
Responded
Mary Hoare
Concerns: Care providers rely on incomplete applicant information and fail to routinely seek GP records or complete thorough service user assessments before admission. This leads to unsuitable placements and a lack of post-admission care plans and risk assessments.
Overdue
Charles Knapp
Concerns: Angel Solutions (UK) Ltd failed to provide essential personal care, secure medical attention for pressure sores, and adhere to care plan staffing requirements. The company's continued operation with inadequate care and record-keeping poses a significant risk of future deaths.
Overdue
Emily Inglis
Concerns: There was no overarching risk management plan for patient care, coupled with deficiencies in record-keeping, including outdated strategies and poor preservation of handover information.
Overdue
Frederick Brooker
Concerns: The care home failed to implement adequate falls prevention, lacking care plans despite identified risks. Multiple falls were not properly investigated or reported, and patient safety was compromised by over-reliance on capacity.
Responded
Jean Cutler
Concerns: The nursing home had an inconsistent approach to falls prevention from wheelchairs, an over-reliance on staff intervention, and an inadequate post-incident investigation with unaddressed systemic issues and incomplete risk assessments.
Responded
Simon Barber
Concerns: Inadequate risk assessments by First Class Care and staff's lack of awareness regarding the importance of reporting safety incidents posed a risk to service users.
Responded
Ruth Gregory
Concerns: Regular unsupervised communal areas in the care home led to resident injuries from falls, highlighting inadequate risk management and supervision arrangements.
Responded
Veronica Gregory
Concerns: Care plans were inadequate, lacked specific risk issues, and were not appropriately reviewed or reassessed, either after incidents or as routine practice.
Responded
Ronald Houchin
Concerns: Falls risk assessments were not consistently followed, resulting in inadequate assistance and supervision for mobilising, and multiple preventable falls for the patient.
Overdue
Beryl Walsh
Concerns: There were multiple missed opportunities to identify the deceased as a high falls risk, escalate care to the falls team, or implement falls prevention equipment and assessments.
Responded
Matthew Arkle
Concerns: Failures in mental health patient risk assessment, undocumented family concerns about unescorted leave, and significant delays in raising the alarm due to chaotic ward conditions and lack of CCTV review policy contributed to the incident.
Responded
Canon Frost
Concerns: Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Responded
Brian Frost
Concerns: Unsafe living conditions, specifically loose flooring, were unaddressed in a frail, elderly priest's accommodation, as diocesan welfare visits failed to conduct health and safety risk assessments.
Overdue
Doris Douthwaite
Concerns: Vulnerable residents with dementia were left unsupervised due to unclear policies, an ambiguous falls risk assessment tool, and a lack of investigation into multiple falls, missing learning opportunities.
Overdue
David Worthington
Concerns: The cycling event's risk assessment inadequately identified a hazardous location with a blind bend, failed to account for high injury potential, and requires a review of its methodology for future events.
Responded
Keith Dransfield
Concerns: An inappropriate observation regime without justification, lack of clear risk assessments, and staff failing to consult patient records, alongside insufficient training, contributed to safety concerns.
Responded
Ruth Perkins
Concerns: A high-risk patient was discharged to a care home with insufficient staffing levels for her needs, particularly lacking 1:1 care, significantly increasing her risk of falls.
Overdue
William Lugg
Concerns: Poor understanding and non-compliance with failed visits procedures, inadequate record-keeping for keyholders, and insufficient guidance on involving police in welfare checks were identified.
Responded
Alfred Meek
Concerns: Poor compliance with enhanced care supervision policies, missed daily assessments, and a lack of action on ward staff concerns about resource shortages left vulnerable patients at risk of falls.
Responded
Gladys Rich
Concerns: The care home failed in fall risk assessment and action plan implementation, while the under-resourced Falls Prevention Service lacked proactive follow-up and discharge mechanisms.
Overdue
Ahmed Tabeche
Concerns: Care home staff lacked a complete understanding of choking risks, and current procedures for visitors providing food are insufficient, failing to adequately protect at-risk patients.
Responded
Stanley Langdon
Concerns: A day care centre provided services without receiving or creating an adequate care plan based on a needs assessment or family discussion, risking future similar accidents.
Overdue