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

    Mrs Doris Douthwaite · 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 Doris Douthwaite, who had vascular dementia and other complex medical conditions, suffered three falls at Greatwood House Residential Care Home over 11–13 February 2018. She sustained a hip fracture, developed bronchopneumonia and died at Willow Wood Hospice on 26 February 2018. Concerns included vulnerable residents being left unsupervised, an unclear falls assessment tool, and the absence of an investigation into Mrs Douthwaite’s falls.

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    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 clear written requirements for communal-area supervision

    Wider context from the report

    “1. The evidence before the court suggested that at Greatwood House, vulnerable residents including residents with dementia such as Mrs Douthwaite, may be left unsupervised at times in communal areas by carers undertaking other tasks. The evidence before the court was that there are currently no clear written requirements in force across HC-One’s homes mandating the attendance of a colleague to monitor the communal area in question before leaving it unattended; ”

    Source location

    Mrs Doris Douthwaite · 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 supervise vulnerable residents in communal areas

    Wider context from the report

    “1. The evidence before the court suggested that at Greatwood House, vulnerable residents including residents with dementia such as Mrs Douthwaite, may be left unsupervised at times in communal areas by carers undertaking other tasks. The evidence before the court was that there are currently no clear written requirements in force across HC-One’s homes mandating the attendance of a colleague to monitor the communal area in question before leaving it unattended; ”

    Source location

    Mrs Doris Douthwaite · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. Coventry

    AI-generated summary

    Ruth Marian Perkin · 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

    Ruth Marian Perkin was admitted to a care home on 9 February 2018, suffered two falls shortly afterwards, and was found to have a right neck of femur fracture after the second fall. She underwent hip repair, later contracted pneumonia, and died on 29 March 2018. The principal concern was that discharge to the care home while her needs were still being assessed, together with staffing and care arrangements, may have increased her risk of falls and death.

    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 staffing to provide required supervision for residents at risk of falls

    Wider context from the report

    “(4) I was informed by the Care Home Manager that if Mrs Perkin not suffered a fracture and had been returned to the care of the Care Home after her second fall, she would have suggested to the hospital that, in view of Mrs Perkin’s tendency to act in disregard of care instructions, she was in fact most likely in need of 1:1 care. (5) I was informed that for the 20 residents at the Care Home there are 5 staff on duty during the day, reducing to 3 staff at night, and my concern is that Mrs Perkin’s discharge to the Care Home under the D2A scheme, when her needs were still being assessed, actually placed her at an increased risk of falls and death as a result. ”

    Source location

    Ruth Marian Perkin · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  3. Nottinghamshire

    AI-generated summary

    George Goldby · 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

    George Goldby choked on a sandwich on 20 March 2017, was taken to hospital, and died on 24 March 2017. The principal concerns were that staff did not follow his speech and language therapy recommendations, including one-to-one supervision and dietary requirements; choking risk assessments and care plans were inadequately managed; and choking incidents were not properly reported or followed by appropriate referrals and reviews.

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    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 supervise residents at high risk of choking during eating

    Wider context from the report

    “(8) Between 19.09.17 and 18.10.17 three separate independent professionals observed residents at high risk of choking eating alone, without supervision. ”

    Source location

    George Goldby · Prevention of Future Deaths report
    Page 2 · 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

    Allocate staff and provide practical supervision during residents’ eating and drinking.

    Verbatim wording from the response

    “1. Allocation of staff to and practical supervision of Residents whilst eating and drinking to assess any issues.”

    Source location

    2018-0104-Response-by-HC-One
    Page 1 · response
    Published 17 June 2018

    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

    Commission a three-day face-to-face dysphagia course for the home’s staff from an external expert provider.

    Verbatim wording from the response

    “We believe that there is no substitute for repeated learning opportunities that help inform staff of the consequences of not supporting Residents effectively and to that end have commissioned a three day face to face dysphagia course for the staff team from an external expert training provider. This is to supplement and extend the learning opportunities already available and refreshed by the team via our online award winning learning platform, Touchstone.”

    Source location

    2018-0104-Response-by-HC-One
    Page 2 · response
    Published 17 June 2018

    Open published response

  4. Gloucestershire

    AI-generated summary

    David Anthony Sketchley · 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

    David Anthony Sketchley, a resident of Ashley House Nursing Home, died after falling through a gap in a bariatric commode chair and sustaining a traumatic perianal injury. The report identified concerns about inadequate supervision, unclear care-plan requirements and definitions of supervision, and insufficient documented assessment of the commode’s suitability.

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    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 define required levels of resident supervision in care plans and guidance

    Wider context from the report

    “At the time of the incident Mr Sketchley was to be supervised. The evidence that I heard was the main carer thought that whilst on the commode Mr Sketchley was to be supervised at all times. The care plan dictated that generally Mr Sketchley was to be supervised regularly. I heard no evidence that staff understood exactly what level of supervision was required. I heard from Demelza James that it is deemed acceptable to not observe / watch a resident who is being supervised but just to listen to them. I heard no evidence that Mr Sketchley’s care plan stated this was a sufficient level of supervision, nor that there are any guidelines to assist staff when making decisions about the level of supervision a resident requires. ”

    Source location

    David Anthony Sketchley · 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 maintain required visual observation during resident supervision

    Wider context from the report

    “At the time of the incident Mr Sketchley was to be supervised. The evidence that I heard was the main carer thought that whilst on the commode Mr Sketchley was to be supervised at all times. The care plan dictated that generally Mr Sketchley was to be supervised regularly. I heard no evidence that staff understood exactly what level of supervision was required. I heard from Demelza James that it is deemed acceptable to not observe / watch a resident who is being supervised but just to listen to them. I heard no evidence that Mr Sketchley’s care plan stated this was a sufficient level of supervision, nor that there are any guidelines to assist staff when making decisions about the level of supervision a resident requires. ”

    Source location

    David Anthony Sketchley · Prevention of Future Deaths report
    Page 2 · 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

    Revise care documentation, supporting guidance and resident-care policies to specify individualised supervision requirements and responsible staff for daily activities.

    Verbatim wording from the response

    “We now advocate the use of a two tier care documentation filing system which is a mandatory process and has been in use since 2017. The main care file is to be housed at the nurse’s station and is where the care plans sit. The second file, which is known as the supplementary file is to be housed at the point of care delivery i.e. in a resident’s bedroom. At the front of the supplementary file is a document named ‘My Day, My Life, and My Portrait’. This document is designed to give an overview of the care needs an individual requires and is available at the point of care delivery, allowing care staff immediate access to imperative information regarding a resident’s care needs. Therefore this document should be reviewed to incorporate an individual’s supervision requirement, including who carries out the supervision, during each activity of daily living requirement.”

    Source location

    2018-0069-Responses
    Page 2 · response
    Published 16 June 2018

    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

    Allocate resources for further investigation of the supervision, commode suitability and investigation deficiencies identified by the coroner, then discuss findings and agree actions and learning.

    Verbatim wording from the response

    “Bupa will allocate resource to undertake further investigations into the issues highlighted above under point 3 by the coroner, which were not covered in the original investigation. Any findings from the new investigation will be discussed at the BCS Clinical Governance Committee and actions and learning’s agreed.”

    Source location

    2018-0069-Responses
    Page 3 · response
    Published 16 June 2018

    Open published response

  5. South Wales Central

    AI-generated summary

    Lee Colin DAVIES · 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

    Lee Colin DAVIES, who was residing at a hostel for homeless people and was known to use illicit drugs intravenously, was found unresponsive in his room the morning after he had been found with a needle in his groin. He was declared deceased by attending paramedics; the inquest conclusion was “Drug Related” and the medical cause of death was recorded as combined drug toxicity and bronchopneumonia. The report raised concern that hostel staff lacked guidance and training on monitoring and safeguarding residents found in circumstances suggesting illicit drug use, creating a risk that residents might be put to bed without ongoing monitoring.

    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 monitor and safeguard residents after suspected illicit drug use

    Wider context from the report

    “(1) The evidence revealed that staff, including night staff at the hostel, have no direct training or guidance on what steps should be taken when a resident is found in circumstances which suggest that they may have injected or otherwise take illicit drugs. The training which they are given, known as a Harm Reduction Course, has some focus on recognising the signs of an overdose and, in appropriate cases, administering opiate drug antidotes, but does not give any guidance or training on monitoring and safeguarding a resident in this situation. Given that many of the residents in this hostel are likely to have alcohol or drug issues, a lack of guidance or training is likely to lead to future deaths in circumstances in which residents are simply put to bed and left without any form of ongoing monitoring. ”

    Source location

    Lee Colin DAVIES · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  6. Nottinghamshire

    AI-generated summary

    Olive Wilmott · 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

    Olive Wilmott was found on the floor of a communal area of a residential care home after suffering a hip fracture. The Inquest concluded that she died from the effects of a urine infection and severe dementia, with the hip fracture a contributory factor. Concerns included possible pushing that was not effectively investigated or referred for safeguarding, and a lack of evidence that required 15-minute observations were provided amid insufficient night-shift staffing.

    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 maintain required 15-minute observation of residents

    Wider context from the report

    “2. That Miss Wilmott was assessed as requiring observation at 15 minute intervals, but there was no evidence that this had been in place and at the time of the event there were insufficient staff in place for her and other residents’ needs (one staff member dedicated per floor of the dementia unit during the night shift). ”

    Source location

    Olive Wilmott · Prevention of Future Deaths report
    Page 1 · concerns

    Open source report

  7. Northamptonshire

    AI-generated summary

    Mrs Freda Cordy · 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 Freda Cordy, a 93-year-old woman with dementia and a history of falls, was admitted to a care home after a fall but received checks only every two hours despite an identified need for constant supervision. She suffered two further falls from her bed, sustaining head injuries and a subdural haematoma, and died in hospital on 1 November 2015. The principal concerns were the lack of constant supervision, the absence of a specific falls risk assessment, and limited consideration of preventative equipment.

    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 care-home supervision at the required constant level

    Wider context from the report

    “1) Despite the medical team identifying a need for constant supervision, the multi disciplinary team placed Mrs Cordy in Templemore Care Home which was only able to provide 2 hourly checks. ”

    Source location

    Mrs Freda Cordy · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Norfolk

    AI-generated summary

    PAMELA JOYCE THURSTON · 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

    Pamela Joyce Thurston, a resident of Cedar Care Home with Alzheimer's dementia, choked on toast after being given food following an approximately 17-hour period without eating and without direct supervision. She developed bronchopneumonia and died in hospital two days later. The substantive concerns included her not being given breakfast, the lack of direct supervision while eating, and the response to the choking incident.

    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 direct supervision during eating for residents who require it

    Wider context from the report

    “Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton. She suffered from Alzheimer's dementia and required prompting in order to eat meals and also supervision in doing so. Approximately two weeks prior to her death, Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out. This was reported to the Care Home Manager and thereafter she was given prunes with stones removed. Her care plan was not altered, but a note was made for the chef to this effect. The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately 5pm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to day shift. On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast. This was given to Mrs Thurston who proceeded to eat the toast so quickly that it became stuck in her airway which caused her to choke. Attempts were made to remove the toast when the attention of the staff was drawn to this by another resident. The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in eating the toast. The nurse was unable to remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics. Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 July 2015 in hospital. It appears that Mrs Thurston ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours. When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later. ”

    Source location

    PAMELA JOYCE THURSTON · 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

    Record meal-service times and provide documented direct observation after missed meals or gaps of eight hours or more.

    Verbatim wording from the response

    “5. Ensure a tick list is in the kitchen area which documents the time a service user is served with a meal in the Home. Where it is noticed that a significant period of time has passed between meals for a service user (eight hours or over), or where a service user has missed a meal, direct observations of the service user should be maintained whilst the service user is eating their meal or snack. The person in charge must designate a member of staff to undertake the observation and this should be documented in the service users notes.”

    Source location

    Thurston-Response
    Page 2 · response
    Published 29 March 2016

    Open published response

  9. Manchester West

    AI-generated summary

    Lee Joseph Rigby · 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

    Lee Joseph Rigby, who had Parkinsonism, swallowing difficulties and other disabilities, died in hospital on 7 October 2015 after choking while eating a sausage roll at his residence. The concerns included him being left unobserved while the sole support worker answered the door, staff not fully understanding the requirement to visually observe him while eating and drinking, and training and procedures not adequately addressing these risks.

    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 of support staff to maintain required visual observation of residents

    Wider context from the report

    “During the Inquest evidence was heard that 1. During the Inquest evidence was heard that i. The support workers do not have keys to the premises at ████████ so that in circumstances where there was only one support worker in the premises that support worker would have to answer the door to allow another support worker entry to the premises. In those circumstances a resident requiring visual monitoring or observation would be left alone and unobserved. Evidence was heard during the course of the Inquest that one of the two support workers could leave the premises during the course of the day so that access to the premises would be required by a support worker either at the commencement of her shift or whenever the support worker left the premises at times when there would only be one support worker in the premises. It was accepted that if every support worker had a key to the premises the sole support worker in the premises would not have to be disturbed to answer the door and a resident, like Mr Rigby, who would not be left unattended at meal times, when Mr Rigby had to be observed at all times, and at any other times whenever he was eating and drinking. ii. Evidence was heard from the support staff that they did not fully understand that monitoring and observing Mr Rigby at all times when he was eating and drinking meant that they should visually observe him at those times. Evidence was also given by members of the support staff that if the telephone rang and there was a need to discuss a resident or something of a private and confidential nature a support worker, who may be the only support worker in the premises at the time, would go into another room to talk in a private and confidential manner, leaving a resident alone and unobserved during the course of the telephone conversation. The support staff did not understand the significance of the words used in the Health Action Plan and Management Guidelines that Mr Rigby should be observed at all times whilst he was eating and drinking and they did not fully understand the significance of observing him in relation to the risks identified in the Plan and Guidelines. iii. The internal training and procedures provided by United Response to the support staff and the procedures in place to address the risks identified by the Health Action Plan and Management Guidelines did not address the risks identified by the Plan and the Guidelines, particularly in relation to a clear understanding by the support staff with regard to observing a resident. ”

    Source location

    Lee Joseph Rigby · Prevention of Future Deaths report
    Page 3 · concerns

    Open source report

  10. Milton Keynes

    AI-generated summary

    Lee Anthony Boden · 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

    Lee Anthony Boden was released from prison to an approved premises in Milton Keynes on 13 February 2015 and was found unresponsive in a bathroom later that night, where drugs and drug paraphernalia were found. He was confirmed dead at 12.10am on 14 February 2015; the stated cause of death was central respiratory depression associated with illicit heroin use. Concerns included limited advance notice of his placement, lack of forward planning, insufficient recognition of his vulnerability, the length of time before he was discovered, and an apparent absence of a protocol for monitoring vulnerable new arrivals.

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    Source evidence

    How this individual concern was interpreted

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

    PFD Monitor interpretation

    Resident remaining undiscovered in bathroom for almost four hours

    Wider context from the report

    “(3) That he had been in the bathroom for almost four hours before he was discovered. ”

    Source location

    Lee Anthony Boden · Prevention of Future Deaths report
    Page 1 · 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

    Existing walk-around, curfew and scheduled self-harm checks were considered adequate to assure residents’ well-being as far as possible.

    Verbatim wording from the response

    “Measures are in place to assure, as far as possible, the well-being of residents at the AP. The regime includes two “walk-around” checks during the day (the last at 5.30pm), as well as a curfew check of all residents at 11pm. Residents with earlier curfews are checked at their curfew time (as was the case with Mr Boden) and those subject to self-harm monitoring procedures are checked in accordance with a monitoring schedule set out in their self-harm management plan.”

    Source location

    2015-0394-Response-by-NOMS
    Page 2 · response
    Published 29 September 2015

    Open published response

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