Recurring concern

Failure to ensure timely required dental care for care-home residents

First to latest report 17 Apr 2019 — 4 Nov 2022

Reports that mention this concern
2
Times this concern has been raised
3
Stated actions linked to this concern
0

What this concern includes

Includes failures of the dental-care process for care-home residents, including identifying dental need, arranging or accessing dental appointments, and providing timely required treatment such as denture updating or replacement.

What is not included
  • Excludes generic care-home staffing, communication, documentation or policy deficiencies unless they directly impair timely required dental care for residents.
  • Excludes general dental-service capacity problems without a specific effect on care-home residents' access to required care.
  • Excludes oral-health education or routine dental-care descriptions that do not identify an unsafe delay, omission or unreliable control.
  • Excludes choking, nutrition or other clinical risks unless the asserted deficiency is specifically a failure to provide required dental care.

Reports and published responses 2 reports

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

  1. Manchester South

    AI-generated summary

    John Fallon · 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 Fallon, who had dementia and was resident at Downshaw Lodge Care Home, choked on partially chewed meat while eating lunch without his dentures on 13 March 2022. The concerns included the lack of routine SALT assessments and diet changes when residents eat without dentures, delays in replacing or updating dentures due to limited dental services, and the absence of routinely available suction machines in care homes.

    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

    Delays in updating or replacing care home residents' dentures

    Wider context from the report

    “2. Evidence was also heard that the limited availability of dental services to care home residents means that situations where dentures require updating/replacing are not being dealt with promptly which means there is a greater risk of choking on food that has not been adequately chewed; ”

    Source location

    John Fallon · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  2. South Yorkshire (Western)

    AI-generated summary

    Patrick Kelly · 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

    Patrick Kelly died from sepsis, part of which was attributed to a dental abscess. The report raised concerns that Roseberry Care Centres did not place adequate importance on dental hygiene and dental services, and lacked adequate policies for missed dental appointments and identifying when appointments were needed.

    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 adequate policies for identifying when dental appointments may be required

    Wider context from the report

    “b) Roseberry Care Centres do not have adequate policies in place to deal with missed dental appointments and the identification of when dental appointments may be required. ”

    Source location

    Patrick Kelly · Prevention of Future Deaths report
    Page 1 · 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 place adequate importance on the provision of dental services to residents

    Wider context from the report

    “a) Roseberry Care Centres do not place adequate weight on the importance of dental hygiene and the provision of dental services to their residents. This has potentially resulted in the worsening of a dental abscess in one case. ”

    Source location

    Patrick Kelly · Prevention of Future Deaths report
    Page 1 · 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