Recurring concern

Inadequate drowning-risk controls during patient bathing

First to latest report 23 Oct 2013 — 8 Oct 2019

Reports that mention this concern: 2
Times this concern has been raised: 2
Stated actions linked to this concern: 3

What this concern includes

Includes failures of controls specifically intended to prevent drowning during patient or resident bathing, including unsuitable bath arrangements, failure to provide safer alternatives where clinically indicated, and inadequate supervision of people with known seizure or comparable risks while bathing.

What is not included

Excludes general drowning hazards in pools, open water, rivers, roads or other settings without a patient- or resident-bathing context.
Excludes generic personal-hygiene, care-quality or staffing deficiencies unless they directly create an unsafe bathing or drowning-risk control failure.
Excludes falls, scalding or other bathing hazards where drowning risk is not the shared unsafe condition.
Excludes ordinary bathing preferences or the use of baths where no material patient-safety or drowning risk is identified.

Trends

Reports over time

Reports mentioning this concern, over time

Reports about this concern issued each year.

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

Most frequent recipients

Reports about this concern sent to each recipient.

North London NHS Foundation Trust1

Pentree Lodge1

Reports and published responses 2 reports

See individual reports that have raised this concern, and the actions taken in response

8 Oct2019
Cornwall and Isles of Scilly
Concerns raised1
1. Failure to safely supervise bathing for residents with a known risk of seizure
This report raised 7 other concerns. They are not shown here because they do not form part of this recurring concern.
Linked response

PENTRE LODGE CARE HOME LIMITED
Stated actions 3
1. PENTRE LODGE CARE HOME LIMITED
  Introduce assisted or escorted bathroom use, showering preference, specialist epilepsy input, and associated seizure-safety measures for residents with diagnosed seizures.
2. PENTRE LODGE CARE HOME LIMITED
  Review all residents’ physical health and seizure histories.
3. PENTRE LODGE CARE HOME LIMITED
  Review seizure-related risk assessments and care plans, implement bathing and showering measures, and provide specialist training after receiving clinical confirmation.
AI-generated summary

Dylan Jay Henty · 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

Dylan Jay Henty had a complex medical history including schizophrenia, a cerebral tumour, communication difficulties and seizures. He went missing after declining prescribed medication on 17 February 2018, and his body was found at Fistral beach on 21 February 2018; the cause of death was recorded as multiple injuries, with no evidence explaining the apparent fall or how he entered the sea. Concerns included an unsupervised seizure in a bath, inadequate awareness of hoarding, medication compliance, inconsistent reporting of absconding incidents, and arrangements for monitoring residents at risk of absconding.

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 safely supervise bathing for residents with a known risk of seizure
Wider context from the report
“i. While it appears to have had no bearing on the circumstances of Dylan’s death, I was concerned to hear evidence of Dylan suffering a seizure in a bath while unsupervised. Similar episodes elsewhere in the country have resulted in criminal prosecutions. It is not clear to me whether reports were made to the CQC, GP and/or care coordinator. You may wish to reflect on the need for clear guidance and training to all staff on the arrangements for those residents with a known risk of seizure to take baths (as opposed to showers) where there is an obvious risk of drowning should a seizure occur. Similarly, those in management positions must be clear about the circumstances in which formal reports should be submitted to relevant bodies and you may feel there is a need to ensure these standards are rigorously checked and met. ”
Source location
Dylan Jay Henty · 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
Introduce assisted or escorted bathroom use, showering preference, specialist epilepsy input, and associated seizure-safety measures for residents with diagnosed seizures.

Verbatim wording from the response
“1. Any resident that is known/diagnosed with seizures is to be encouraged to be assisted/escorted in the bathroom, in compliance with the relevant acts, dignity and consent from the resident. A shower is encouraged/advised over a bath and the relevant measures/training to be put in place. Care Plans and Risk Assessments to be done with the support and advice of the Specialist Epilepsy Nurse. All relevant physical illnesses where an ambulance/out of hours doctor are called, accidents or hospital admissions are reported to the relevant bodies i.e. Care co-ordinators. The GP has access to this information via R.I.O. A report is also sent to the GP from the relevant bodies.”

Source location
2019-0334-Response-by-Pentree-Lodge-Care-Home
Page 1 · response
Published 10 November 2019
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
Review all residents’ physical health and seizure histories.

Verbatim wording from the response
“2. Since the inquest management of the home have reviewed all residents physical health. Management have picked up that another resident who has a history of seizures, she hasn’t had a seizure since being in the care home for over 5 years but has not been reviewed by any health professional for at least 10 years regarding her history of seizures. This is now being reviewed by ████████ When confirmation of this is sort the home will review its Risk Assessments and Care Plans and put in place the relevant measures surrounding bathing and showering, training on this specialist area will be undertaken by all staff.”

Source location
2019-0334-Response-by-Pentree-Lodge-Care-Home
Page 1 · response
Published 10 November 2019
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
Review seizure-related risk assessments and care plans, implement bathing and showering measures, and provide specialist training after receiving clinical confirmation.

Verbatim wording from the response
“2. Since the inquest management of the home have reviewed all residents physical health. Management have picked up that another resident who has a history of seizures, she hasn’t had a seizure since being in the care home for over 5 years but has not been reviewed by any health professional for at least 10 years regarding her history of seizures. This is now being reviewed by ████████ When confirmation of this is sort the home will review its Risk Assessments and Care Plans and put in place the relevant measures surrounding bathing and showering, training on this specialist area will be undertaken by all staff.”

Source location
2019-0334-Response-by-Pentree-Lodge-Care-Home
Page 1 · response
Published 10 November 2019
Open published response
23 Oct2013
Inner North London
Concerns raised1
1. Possible drowning hazard associated with patient bathing in baths
This report raised 3 other concerns. They are not shown here because they do not form part of this recurring concern.
No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
AI-generated summary

John Frank Henry LANSDOWNE · 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

John Frank Henry Lansdowne, who had schizophrenia and a history of serious suicide attempts, was admitted to St Pancras Hospital under section 3 of the Mental Health Act after talking about taking his life. He was found submerged in a bath on 18 May 2012 and died shortly afterwards. Concerns included unclear observation timings, an unrecovered observation sheet, inconsistent staff understanding of observations while a patient was bathing, and the use of baths rather than walk-in showers.

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
Possible drowning hazard associated with patient bathing in baths
Wider context from the report
“4. Mr Lansdowne died in the bath, it is possible as a result of drowning. Mr Lansdowne’s family explained at inquest that in other hospitals where he had been treated, only walk in showers are used. ”
Source location
John Frank Henry LANSDOWNE · Prevention of Future Deaths report
Page 2 · concerns
Open source report