Recurring concern

Failure to provide fundamental personal care and welfare

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First reported 24 Sep 2014•Latest report 22 Jul 2024

Definition

What this concern includes

Includes failures in the bounded delivery of fundamental personal care and general welfare to people receiving care, including meeting basic needs for warmth, hygiene, grooming, clean and adequate clothing, safe assistance with meals, comfort and comparable essential daily care needs.

Not included

  • Excludes failures confined to a specific named care process, such as continence care, nutrition and hydration management, pressure-ulcer care or moving and handling, when that process supplies the more specific supported concern.
  • Excludes generic staffing, training, documentation or management deficiencies unless they directly result in failure to provide fundamental personal care or welfare.
  • Excludes clinical assessment, diagnosis, treatment, referral or escalation failures where basic personal care and welfare are not the unsafe condition.
  • Excludes ordinary dissatisfaction or preferences about care where no failure to meet an essential personal-care or welfare need is identified.
Reports
15

Distinct published reports

Individual concerns
15

A report can raise multiple concerns

Date range
2014–2024

First to latest report issue date

Stated actions
21

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

University Hospitals Sussex NHS Foundation Trust3
East London NHS Foundation Trust2
NHS England2
Barts Health NHS Trust1
Berrycroft Manor1
Betsi Cadwaladr University LHB1
Care Quality Commission1
Care UK1
Care UK Community Partnerships Ltd1
CSC Computer Sciences Limited1
Department of Health and Social Care1
East Sussex Healthcare NHS Trust1
Essex Partnership University NHS Foundation Trust1
Guy'S and St Thomas' NHS Foundation Trust1
HM Prison and Probation Service1

Concerns and responses across reports

Only concerns grouped under this recurring concern are included. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Sidney Barnett · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Sidney Barnett, a care home resident whose health was gradually declining, was found inadequately clothed and cared for, struggling to eat alone and unattended, and later died in hospital from pneumonia on 3 January 2015. The principal concerns were inadequate observation and general welfare, unclear rules about open windows, and inadequate and insufficiently structured safeguarding investigations.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Insufficient care for clients’ general welfare

    Wider context from the report

    “2. There was an insufficiency of care shown to the deceased in terms of his general welfare (whether he was warm enough, whether he was washed and shaved, whether he was able to take his meals safely, whether his clothing was adequate and clean etc.). ”

    Source location

    Sidney Barnett · Prevention of Future Deaths report
    Page 1 · concerns

    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

    Implement room-visit charts with senior-care-staff checks and hourly, or 15-minute meal-room, resident observations.

    Verbatim wording from the response

    “All resident’s with in the home have a room visit chart in place, this is to be completed by care staff and checked by Senior care staff. This form must be completed when a resident wishes to remain in their room and or takes meals in their rooms. A resident is to be checked hourly and every fifteen mins if meals are taken in rooms.”

    Source location

    2015-0222-Response
    Page 1 · response
    Published 12 June 2015

    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

    Deliver rolling dignity training for all staff, focusing on personal-care standards and dignity.

    Verbatim wording from the response

    “All personal care forms to be completed in care plans documentation must be made if a residents refuses care. A rolling programme of dignity training (DELIVERED BY THE MANAGER) is in place for all staff focusing on personal care standards and dignity.”

    Source location

    2015-0222-Response
    Page 1 · response
    Published 12 June 2015

    Open published response

  2. Brighton and Hove

    AI-generated summary

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mrs. Evelyn KENNEDY was an 89-year-old woman who died in hospital on 29 October 2014 after admission following recurrent falls. The inquest concluded that she died of hospital-acquired pneumonia and that her death was probably accelerated by a short time because of the effects of her five-day admission to the Acute Medical Unit. Concerns included incomplete handover and poor personal care, missing identification and risk bands, inadequate monitoring and documentation, missed medication and nutritional support, and failures to escalate clinical deterioration.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to provide required personal and oral care

    Wider context from the report

    “(1) Once again my concerns involve the Acute Medical Unit (AMU). (2) Mrs. KENNEDY was transferred from AMU in a chair, not a trolley. (3) Handover was incomplete and unhelpful. (4) She arrived unkempt. (5) She had porridge leaking from her mouth; it took 20 mouth sponges to give her adequate mouth care. (6) She felt cold and said she was cold. (7) She had been incontinent of faeces and had not been cleaned for some time. (8) She had no name wrist band. (9) In spite of known allergies she had no allergy wrist band. (10) In spite of falling regularly she had no falls risk wrist band. (11) She still had an IV cannula in place; this should have been removed after 72 hours. (12) Her daily catheter care bundle had not been completed for 3 days. (13) She had no fluid charts for 16th, 17th, 18th, 19th or 20th. (14) Care plans were not completed for 17th, 18th, 19th or 20th. (15) Repositioning charts were incomplete or poor for 16th, 17th, 18th and 19th. (16) The handling assessment was not completed for 16th, 18th, 19th or 20th. (17) No food chart was completed for her entire time in AMU. (18) She had pressure damage to her hips and bottom. (19) No daily oral assessment was completed for her entire time on AMU. (20) She was not weighed. (21) The malnutrition tool was not completed. (22) Her bowel movements were not recorded. (24) NEWS scores of 4 to 9 had not been escalated to doctors nor filled in on her drug chart. PLUS (25) No personal care over the weekend of 18th and 19th. (26) No senior review over that weekend. (27) Not written up for her Sertraline, therefore not given (28) Not written up for any food supplements until 21st October. (29) She should have been specialled, but wasn’t. Once again AMU has been found to be chaotic and not fit for purpose. ”

    Source location

    Mrs. Evelyn KENNEDY · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Inner North London

    AI-generated summary

    Andrew James AITKEN · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Andrew Aitken was admitted to hospital on 10 June 2014 after taking a drug overdose, was treated and discharged on 16 June. Two months later he was found dead at home from amitriptyline toxicity, without having accessed mental health care in the meantime. Concerns included the handling of the remaining tablets, failure to seek records of a previous psychiatric admission, lack of direct referral to community mental health services despite him having no GP, and his discharge without clothes or shoes.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Failure to ensure patients have appropriate clothing and footwear at discharge

    Wider context from the report

    “4. I was told that Mr Aitken was discharged from hospital in gown and socks, with no clothes or shoes. I understand that East London Trust has now decided to undertake a serious incident review, but I am concerned that ████████ has already written to the Royal London Hospital, has received no response to that letter, and has been told that there is no ongoing investigation into her complaint. ”

    Source location

    Andrew James AITKEN · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 ward had done everything possible regarding discharge without clothes or shoes, so the safeguarding alert was closed.

    Verbatim wording from the response

    “The investigation involved communicating with ████████ who is the senior sister on ward 11C. She told me that she remembered this man very well. She stated that he was medically fit and the psychiatry team had discharged him; he was willing to go home and so they could not keep him in hospital. He did not have any clothes with him and he told staff that no one could bring him any in. The Trust booked and paid for a taxi to take him home as they did not want him going home on public transport in hospital pyjamas. The ward did receive a complaint in June whereby a safeguarding alert was raised, although it was deemed that the ward had done everything it could at the time and so the safeguarding was closed.”

    Source location

    2014-0561-Response-by-Barts-Health-NHS-Trust
    Page 2 · response
    Published 15 December 2014

    Open published response

  4. West Yorkshire Eastern

    AI-generated summary

    Barry Horrocks · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Barry Horrocks, who had vascular dementia and other physical and mental health problems, was serving a prison sentence at HMP Wakefield when he suffered a cerebral event and died in hospital on 5 April 2013. The principal concern was the lack of coordinated care and suitable support for his deteriorating ability to manage daily living and intimate personal care, including personal hygiene, toileting and medication.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unavailability of social-services support for activities of daily living in prison

    Wider context from the report

    “(2) It was when in Prison that his immediate environment, that is his Prison cell was not in any way adapted to assist with activities of daily living. The ‘Social Services’ input’ which was a vital element of his care obviously could not be replicated whilst he was in prison. Such an input though was needed and necessary for his well-being. ”

    Source location

    Barry Horrocks · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  5. Sunderland

    AI-generated summary

    Leonard Henry Hudson · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Leonard Henry Hudson fell at home, was admitted for surgery to repair a fractured right femur, later underwent a below-knee amputation, and died from bronchopneumonia on 19 March 2014. Concerns included failures in pressure-ulcer reporting and management, delayed referral to the foot protection team, incomplete nursing documentation, variable classification of heel injuries, and other deficiencies or confusion in records, mobilisation, fluid restrictions, physiotherapy, hygiene arrangements and diabetes information.

    Read the report on judiciary.uk

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below.

    PFD Monitor interpretation

    Unclear toileting arrangements and unmet hygiene needs

    Wider context from the report

    “During the course of Mr Hudson’s in-patient admission from the 13th May 2013 to the 13th of August 2013, staff did not follow the requirements of the Trust’ Prevention and Management of Pressure Ulcers Policy in that incident reports were not submitted. Due to the co-morbidities of Mr Hudson, he ought to have been identified as having a higher risk factor. Mr Hudson ought to have been referred to the foot protection team in a more timely manner. The nursing documentation was not as comprehensive as it ought to have been. The classification of Mr Hudson’s heel injuries was “variable”. From the evidence given by ████████, the Tissue Viability Specialist Practitioner, that these matters have been or will be addressed and I was encouraged to learn about that, and the Awareness and Training Programme together with the work of the Foot Protection Team. During the course of the evidence some other matters of concern were raised, particularly those relating to the mobilisation of Mr Hudson. I would like to draw them to your attention, as follows: - 1) there were episodes of inadequate record keeping; for example, although the family had met with medical staff to discuss concerns, there appeared to be no available record or the action taken thereafter; also Mr Hudson was to have the benefit of an Exogen machine for 20 minutes each day to stimulate the healing of the bone, but there appeared to be no records about this; 2) there was confusion about Mr Hudson being moved from the bed to his chair by hoist; 3) there was some degree of confusion about any fluid restrictions for Mr Hudson: the family were under the impression that there would be fluid restriction, but in evidence this appeared to be related to six occasions following Mr Hudson’s dialysis; 4) although physiotherapists attended the ward on two occasions per day, Mr Hudson was absent from the ward for three days having dialysis and there was no contingency provision for physiotherapy; 5) there appeared to be some conflict with regard to the arrangements made for Mr Hudson to go to the toilet and whether his hygiene needs were met; 6) it was accepted that Mr Hudson had Type 2 Diabetes but there was an impression that this was Type 1. All of these matters dented the trust and confidence that the family had in the provision of healthcare and although they submitted to me that Mr Hudson had died of Natural Causes contributed to by neglect, I did not make that finding. However, some aspects of Mr Hudson’s care could impact on the care of others and you will appreciate my duty to draw these matters to your attention. I know that some of them have already been addressed, particularly in respect of the matters received in evidence by ████████ but I shall be glad of your response to this Report To Prevent Future Deaths. ”

    Source location

    Leonard Henry Hudson · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
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Data last updated 7 September 2026