Recurring concern

Failure to reliably supervise and monitor residents in care accommodation

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First reported 1 Dec 2013•Latest report 21 May 2026

Definition

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.

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: 34
Individual concerns: 39
Date range: 2013–2026
Stated actions: 35

Reports 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.

Care Quality Commission4

Department of Health and Social Care2

Hc-One Limited2

Alexandra View Care Centre1

Aria Healthcare Group Ltd1

Bolton Borough Council1

Bournemouth Churches Housing Association Limited1

Bowden Derra Park Limited1

Bupa Care Homes1

Care UK1

Cedar House Nursing and Residential Home1

Chilton Care Centre1

Coombe Dingle Nursing Home1

Essex County Council1

Essex Partnership University NHS Foundation Trust1

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.

20 Aug2015
Manchester South
Concerns raised1
1. Poor observation of residents’ basic needs
This report raised 11 other concerns. They are not shown here because they do not form part of this recurring concern.
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
23 Dec2014
Portsmouth and South East Hampshire
Concerns raised1
1. Inadequate staffing to supervise residents in communal areas during use
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Respondent positions 1
1. Position
  Staffing levels were not inadequate; the unit was over-staffed against industry averages and had appropriate numbers to meet residents’ needs.
  Stated by Care UK Community Partnerships LtdDisputes the concern
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
12 Dec2013
West Yorkshire (Western)
Concerns raised2
1. Lack of arrangements to record and monitor resident absences
2. Failure to react appropriately to inappropriate or particularly lengthy resident absences
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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
1 Dec2013
Surrey
Concerns raised1
1. Failure to restrict unsupervised access to stairs for vulnerable residents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No respondent-stated action or position is linked to these concerns in the published data.
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

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Poor observation of residents’ basic needs

Concerns raised1

Inadequate staffing to supervise residents in communal areas during use

Respondent positions A position is what a respondent says about the concern when they do not describe a specific action.1

Concerns raised2

Lack of arrangements to record and monitor resident absences

Failure to react appropriately to inappropriate or particularly lengthy resident absences

Concerns raised1

Failure to restrict unsupervised access to stairs for vulnerable residents

Respondent positions 1