Recurring concern

Failure to reliably supervise and monitor residents in care accommodation

First to latest report 1 Dec 2013 — 21 May 2026

Reports that mention this concern
34
Times this concern has been raised
39
Stated actions linked to this concern
35

What this concern includes

Includes failures of required resident observation, supervision, bathroom or location monitoring, and arrangements for detecting or responding to unexplained absence in care or supported accommodation.

What is not included
  • Condition-specific clinical monitoring where general resident supervision is reliable
  • Custody checks or hospital observation outside care accommodation
  • Generic staffing or documentation failures that do not impair resident supervision or presence awareness

Reports and published responses 34 reports

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

  1. Manchester South

    AI-generated summary

    Elsie Clarke · 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

    Elsie Clarke was a resident at Hurst Hall care centre and developed significant pneumonia on 10 February 2015, dying later that day. The report identified concerns about missed opportunities to summon medical help, inadequate staff training and observations, failures in record-keeping and handover, and deficiencies in out-of-hours medical processes and death reporting.

    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

    Poor observation of residents’ basic needs

    Wider context from the report

    “(3) The level and quality of observation of the residents were very poor and did not include even some of the most basic issues such as whether the patient was warm, thirsty etc. ”

    Source location

    Elsie Clarke · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  2. Portsmouth and South East Hampshire

    AI-generated summary

    Alois Piska · 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

    Alois Piska fell in the lounge of his nursing home on 29 May 2014, where no staff member was present, and sustained a non-survivable head injury. He died in hospital on 31 May 2014; the substantive concern was inadequate staffing to supervise residents in communal areas whenever they were in use.

    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

    Inadequate staffing to supervise residents in communal areas during use

    Wider context from the report

    “There were inadequate numbers of staff at Harry Sotnick House to supervise residents in communal areas at all times when such areas are in use. ”

    Source location

    Alois Piska · 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

    Staffing levels were not inadequate; the unit was over-staffed against industry averages and had appropriate numbers to meet residents’ needs.

    Verbatim wording from the response

    “On the 29th May I can confirm that the occupancy of the unit in question was 15 residents. The staff deployed to support these residents were: 1 Registered Nurse and 5 care staff which is a ratio of 1 member of staff to 2.5 residents.”

    Source location

    2014-0553-Response-by-Care-Uk
    Page 1 · response
    Published 23 December 2014

    Open published response

  3. West Yorkshire (Western)

    AI-generated summary

    Jane Dyson Gabbitas · 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

    Jane Dyson Gabbitas was found unconscious in an abandoned car on 2 March 2013 and died at the scene despite resuscitation attempts. The inquest concluded that she died after ingesting sufficient quantities of alcohol and gabapentin to cause her death. The report raised concerns about the failure to record and monitor her absence from the SHARE accommodation unit and to respond appropriately to lengthy or inappropriate absences.

    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

    Lack of arrangements to record and monitor resident absences

    Wider context from the report

    “The inquest revealed a period of time on the day of her death from approximately 1.40pm to 6pm when Mrs Gabbitas was absent from SHARE, and she never returned, her body then having been discovered some distance away. Staff at SHARE were aware that she had indicated an intention to go out, but apparently were not aware of the full extent of her absence until telephoned by Mrs Gabbitas’ daughter to say her mother’s body had been found by police. It was not clear if there was any sign-in /out arrangement or any reception facility at SHARE to account for absences. I consider that, although I did not find that Mrs Gabbitas’ death would have been prevented by earlier attention to her absence, there is a risk that future deaths may occur in similar circumstances if no action is taken to record and monitor absence, albeit informally (in keeping with the nature of the care in the SHARE unit), and to react appropriately to absences which appear to be inappropriate or particularly lengthy. ”

    Source location

    Jane Dyson Gabbitas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

    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 react appropriately to inappropriate or particularly lengthy resident absences

    Wider context from the report

    “The inquest revealed a period of time on the day of her death from approximately 1.40pm to 6pm when Mrs Gabbitas was absent from SHARE, and she never returned, her body then having been discovered some distance away. Staff at SHARE were aware that she had indicated an intention to go out, but apparently were not aware of the full extent of her absence until telephoned by Mrs Gabbitas’ daughter to say her mother’s body had been found by police. It was not clear if there was any sign-in /out arrangement or any reception facility at SHARE to account for absences. I consider that, although I did not find that Mrs Gabbitas’ death would have been prevented by earlier attention to her absence, there is a risk that future deaths may occur in similar circumstances if no action is taken to record and monitor absence, albeit informally (in keeping with the nature of the care in the SHARE unit), and to react appropriately to absences which appear to be inappropriate or particularly lengthy. ”

    Source location

    Jane Dyson Gabbitas · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Surrey

    AI-generated summary

    John William Tugwell · 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 William Tugwell, a nursing-home resident aged 79, was found at the bottom of the stairs after an unwitnessed fall and later died from injuries including skull fractures and an extra cranial scalp haematoma. The principal concern was that, despite a documented history of previous falls, he had unsupervised access to two sets of stairs at the home.

    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 restrict unsupervised access to stairs for vulnerable residents

    Wider context from the report

    “Although Mr Tugwell was clearly a falls risk given his documented history of previous falls at the home, he was allowed unsupervised access to the two sets of stairs at the home. I would be grateful if you could re consider the appropriateness of allowing such vulnerable and unsupervised residents access to the stairs given the potential for serious injury. ”

    Source location

    John William Tugwell · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

Actions and positions describe what organisations say in published responses. Implementation is not independently verified.

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Data last updated 7 September 2026