Recurring concern

Unreliable emergency response arrangements in care homes

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First reported 15 Feb 2016•Latest report 31 Oct 2025

Definition

What this concern includes

Includes care-home arrangements for recognising emergencies, seeking medical or emergency assistance, activating emergency calls, allocating responsibilities, using emergency procedures and coordinating the immediate response, including the anchor's inadequate training of non-clinical staff and failures to provide defined emergency procedures.

Not included

Excludes generic care-home staffing, training or communication deficiencies unless they directly impair the care home's emergency-response arrangement.
Excludes failures limited to ambulance dispatch, attendance, hospital handover or treatment after the emergency response has been appropriately initiated.
Excludes routine clinical care, welfare checks or resident supervision where no care-home emergency-response deficiency is identified.
Excludes generic first-aid or resuscitation competence concerns unless they are part of the wider care-home emergency-response arrangement.
Excludes the narrower concern concerning care staff's ability to initiate an appropriate 999 or 111 call when that is the only supported failure.

Reports: 17
Individual concerns: 19
Date range: 2016–2025
Stated actions: 26

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 Commission3

Wolverhampton City Council2

Avery Healthcare Group1

Barchester Healthcare Limited1

Broadland View Care Home1

Castlehill Specialist Care Centre1

Community Disability Nurse1

Dairy Lane Care Centre1

Hampshire County Council1

Health and Safety Executive1

Healthcare Management Solutions Ltd1

Hibiscus House Domiciliary Care Agency1

Hibiscus Housing Association Limited1

Hill Care Group1

Independent Futures1

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.

5 Jan2021
Hampshire, Portsmouth and Southampton
Concerns raised1
1. Insufficient training for residential home staff in recognising intracranial injury
This report raised 1 other concern. 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.
Actions described in response 1
1. Action
  Require residential staff to complete a standalone learning module on falls management, including the risk of head injury.
  Stated by Hampshire County CouncilStated planned
AI-generated summary

Arthur Edward JOHNSON · 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

Arthur Edward JOHNSON died on 20 April 2020 after an unwitnessed fall at a residential home caused a head injury and intracerebral haemorrhage; a spontaneous intracranial haemorrhage also contributed to the death. Concerns were raised that the residential home’s post-falls process did not clearly distinguish between possible and suspected head injury or specify when 999/111 should be called, and about staff training to recognise intracranial injury.

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 training for residential home staff in recognising intracranial injury
Wider context from the report
“Oakridge House Residential Home is staffed by non-medically trained personnel. The “Post-Falls” process/policy direct that 999/111 should be called when a head injury is suspected. The evidence at inquest indicated that where a head injury was considered a possibility 999/111 was not called. My concern is that the present process does not give adequate direction, provide sufficient clarity nor distinguish between “possible” and “suspected” head injury. It is not clear when 999/111 should be called. Further, I have concerns in relation to the training provided to assist Residential Home staff in the recognition of intracranial injury. ”
Source location
Arthur Edward JOHNSON · 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
Require residential staff to complete a standalone learning module on falls management, including the risk of head injury.

Verbatim wording from the response
“Regarding staff training, previously staff were trained in how to respond to head injury events during our “Emergency Aid” course. Following your comments, this has been reviewed. Although staff working in a residential setting are not clinically trained, they will now be required to participate in a standalone learning module designed specifically to focus on falls management issues, including risk of head injury. This will compliment other practice guidance for example risk assessment and risk management plans for mobile elderly people in a communal living setting.”

Source location
2021-0003-Response-from-Hampshire-County-Council-Redacted
Page 1 · response
Published 14 January 2021
Open published response
3 Apr2020
Black Country
Concerns raised1
1. Delays in seeking medical review after head injury
This report raised 12 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

Edna May Davenport · 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

Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

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 seeking medical review after head injury
Wider context from the report
“(8) The deceased was an elderly lady who had suffered a head injury and was known to be anti-coagulant medication, yet no medical review was sought until an ambulance was called on 29/11/19 when the deceased became unresponsive. A concern was raised by hospital staff on her admission and a safe guarding referral was made. ”
Source location
Edna May Davenport · Prevention of Future Deaths report
Page 3 · concerns
Open source report
28 May2019
Teesside and Hartlepool
Concerns raised1
1. Lack of clarity about the existence of a DNA CPR
This report raised 3 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.
Actions described in response 1
1. Action
  Implement a DNACPR notification system using door markers and prominent notices in residents’ room folders.
  Stated by Rossmere Park Care CentreStated completed
AI-generated summary

Gloria Elizabeth MEKINS · 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

Gloria Elizabeth Mekins was a resident at Rossmere Park Care Home when she choked while eating a snack on 2 October 2018 and died at the care home. Concerns included the absence of first aid by the staff member who found her, confusion about the existence of a DNA CPR leading to a delay in first aid, and the care home's failure to investigate or address these issues.

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 clarity about the existence of a DNA CPR
Wider context from the report
“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”
Source location
Gloria Elizabeth MEKINS · 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
Implement a DNACPR notification system using door markers and prominent notices in residents’ room folders.

Verbatim wording from the response
“Staff are advised which resident has a DNACPR Notice by means of a whiteboard within the Nurse’s office at Rossmere Park Care Centre – with the same facility in the Senior’s office on the Ground Floor. This shows against each resident’s room, whether a DNACPR is in place and the date it expires. The Daily Handover sheets also show clearly against each room which resident has a DNACPR.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 2 · response
Published 2 August 2019
Open published response
28 Mar2018
Derby and Derbyshire
Concerns raised1
1. Failure to know how to deflate patient mattresses in an emergency
This report raised 1 other concern. 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.
Actions described in response 1
1. Action
  Complete and provide a reflective account addressing CPR procedures, emergency mattress deflation, and the need for a firm surface.
  Stated by Royal College of NursingStated completed
AI-generated summary

Donald Martin · 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

Donald Martin, a 96-year-old resident of Langdale Heights Nursing Home with Chronic Obstructive Pulmonary Disease receiving long-term oxygen treatment, was observed struggling to breathe on 14 January 2016 and was pronounced deceased shortly after the ambulance arrived. The court found non-causative deficiencies in the emergency response before the ambulance service arrived. Concerns included whether the nurse in charge understood why or when CPR should be carried out on a flat surface and her lack of knowledge about deflating patient mattresses during an emergency.

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 know how to deflate patient mattresses in an emergency
Wider context from the report
“Nurse Cecilia Banjoko was the nurse in charge on 14 January 2016. During the course of the inquest she gave evidence that she no longer works at Langdale Heights Nursing Home and is now a nurse at The New Lodge Nursing Home in Mickleover, Derby. She gave evidence that since Mr Martin's death she had attended and completed practical training in relation to basic life support and cardio-pulmonary resuscitation (CPR). However, she also gave evidence that (i) she did not know then and still did not know why the ambulance controller had asked her to move Mr Martin from his bed to the floor prior to the arrival of the ambulance crew and (ii) she did not know how to deflate a patient’s mattress at the time of Mr Martin's death and was still unaware of how to do so. I am concerned that Nurse Banjoko: (i) may not understand why or when it appropriate to carry out CPR on a flat service; (ii) does not know how to deflate patient mattresses in the event of an emergency. ”
Source location
Donald Martin · 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
Complete and provide a reflective account addressing CPR procedures, emergency mattress deflation, and the need for a firm surface.

Verbatim wording from the response
“Further to the Regulation 28 Report provided to Ms Cecilia Banjoko, please find enclosed a copy of her reflective piece following the Inquest in this matter.”

Source location
2018-0166-Response-by-Royal-College-of-Nursing
Page 1 · response
Published 8 July 2018
Open published response
14 Feb2018
Sunderland
Concerns raised1
1. Failure of care home staff to respond appropriately to requests for an ambulance following falls
This report raised 2 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

Mr John Thomas Lambton · 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

Tom was admitted to Sunderland Royal Hospital after a series of unwitnessed falls or incidents while in respite care, and was found to have a fractured neck of femur and an active subdural haemorrhage. He underwent surgery and monitoring but deteriorated 18 days after admission following a suspected subdural re-bleed and died on 27 August 2017. The concerns were that care home staff made assumptions about his health, disregarded his request for an ambulance, and communicated insufficiently with the GP.

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 care home staff to respond appropriately to requests for an ambulance following falls
Wider context from the report
“(2) Care home staff disregarded Tom’s request for an ambulance following the fall ”
Source location
Mr John Thomas Lambton · Prevention of Future Deaths report
Page 2 · concerns
Open source report
10 Jan2018
Staffordshire South
Concerns raised1
1. Failure to seek medical assistance following seizures
This report raised 12 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

John Keith Edwards · 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 Keith Edwards, aged 64, was admitted to a care home for respite and subsequently suffered falls, seizures, reduced mobility, pressure sores and a rapid decline before dying in a nursing home on 19 December 2016. Concerns included inadequate care-home policies and care, failures to seek medical assistance and recognise deterioration, poor record-keeping, and inappropriate placement for his complex needs.

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 seek medical assistance following seizures
Wider context from the report
“(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate (2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care (3) Care Home staff applied a seizure policy which was not specific to the resident. (4) Care Home staff failed to seek medical assistance following seizures. (5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home. (6) Care records were retrospectively filled in. (7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done. (8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP. (9) Non patient specific dressings were used on pressure sores. (10) A non-patient specific mattress was used on his bed. (11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition. ”
Source location
John Keith Edwards · Prevention of Future Deaths report
Page 2 · concerns
Open source report
15 Feb2016
Portsmouth and South East Hampshire
Concerns raised1
1. Unavailability of useful equipment in nursing home emergency resuscitation packs
This report raised 3 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

James Robertson · 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

James Robertson died on 22 July 2015 while resident at Cams Ridge Care Home, after he was last checked at around 13.00 hours and found apparently deceased at around 15.30 hours. Concerns included inaccurate recording of care-check times, delayed recognition of his DNACPR status, and inadequate equipment in the emergency resuscitation pack, particularly the lack of a suction unit.

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
Unavailability of useful equipment in nursing home emergency resuscitation packs
Wider context from the report
“3) I was also told that there are no national standards for what should be included in emergency resuscitation packs kept at nursing homes and in consequence, the pack brought to assist Mr Robertson was lacking useful equipment, particularly a suction unit. ”
Source location
James Robertson · Prevention of Future Deaths report
Page 1 · concerns
Open source report

Data last updated 7 September 2026

What this concern includes

Not included

Reports over time

Concerns raised1

Insufficient training for residential home staff in recognising intracranial injury

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Delays in seeking medical review after head injury

Concerns raised1

Lack of clarity about the existence of a DNA CPR

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure to know how to deflate patient mattresses in an emergency

Actions described in response An action is something a respondent says it has done, is doing, or plans to do in response to the concern raised.1

Concerns raised1

Failure of care home staff to respond appropriately to requests for an ambulance following falls

Concerns raised1

Failure to seek medical assistance following seizures

Concerns raised1

Unavailability of useful equipment in nursing home emergency resuscitation packs

Actions described in response 1

Actions described in response 1

Actions described in response 1