Recurring concern

Failure to ensure people are placed in care settings suitable for their needs

First to latest report 23 May 2014 — 10 Oct 2025

Reports that mention this concern
19
Times this concern has been raised
20
Stated actions linked to this concern
12

What this concern includes

Includes failures of the care-placement process to assess needs, identify suitable settings, match people to placements, or move them when an existing setting cannot safely meet their needs, including residential and nursing placements and comparable care settings.

What is not included
  • Excludes generic discharge, transfer or care-coordination failures where placement suitability is not the identified unsafe condition.
  • Excludes shortages or unavailability of placements unless they directly result in a person being placed or left in a setting unsuitable for their needs.
  • Excludes inappropriate hospital, mental-health or custodial placements unless the assertion specifically concerns the suitability of a care placement for the person's needs.
  • Excludes failures limited to care quality after a placement is suitable, where the placement decision or suitability assessment is not deficient.

Reports and published responses 19 reports

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

  1. Essex

    AI-generated summary

    Jillian Anne Steedman · 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

    Jillian Anne Steedman died at Pitsea Station on 12 May 2023 after intentionally going into the path of an oncoming train, following a deterioration in her mental health. The report identifies concerns including failures in information sharing, risk assessment, care planning, escalation, crisis response, and review of her placement and support arrangements.

    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

    Inappropriate care-home placement for patient needs

    Wider context from the report

    “(5) Mrs Steedman was discharged to the care home on 11 April 2023 from mental health hospital following an admission of over 12 months and previously failed discharges. Evidence was heard Mrs Steedman was not appropriately placed in the Care Home based on her needs and the local authority were on notice that another care home had refused to admit Mrs Steedman due to her mental health. There was no review and the s117 care plan had not been updated since 13 September 2022. ”

    Source location

    Jillian Anne Steedman · 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

    Discuss professional curiosity with teams, remind staff to review care-home paperwork and consult carers, and provide support sessions on asking appropriate questions.

    Verbatim wording from the response

    “Response: We refer to our reply above under concern 4 in respect of care plans and risk assessments. In addition, as part of team reflections in this matter, the importance of professional curiosity was discussed and the team were reminded that they should review care home paperwork (where access is possible) and also speak with carers within the home. Support sessions were provided on asking right questions using professional curiosity and how this would have given more opportunity to understand Mrs Steedman’s needs and risks, whilst acknowledging that the Care Home may in turn approach the Trust with regards to any information or support required.”

    Source location

    Response from Essex Partnership University
    Page 3 · response
    Published 14 October 2025

    Open published response

    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

    Essex County Council is responsible for responding to concerns about placement appropriateness and updating the section 117 care plan.

    Verbatim wording from the response

    “Concern 5) Mrs Steedman was discharged to the care home on 11 April 2023 from mental health hospital following an admission of over 12 months and previously failed discharges. Evidence was heard Mrs Steedman was not appropriately placed in the Care Home based on her needs and the local authority were on notice that another care home had refused to admit Mrs Steedman due to her mental health. There was no review and the s117 care plan had not been updated since 13 September 2022”

    Source location

    Response from Essex Partnership University
    Page 2 · response
    Published 14 October 2025

    Open published response

  2. Suffolk

    AI-generated summary

    David Thomas BENDELL · 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 Bendell fell while trying to use a commode at home after being discharged from hospital following a stroke, and later died in hospital from a large brain bleed. The report raises concern that rehabilitation options limited to specialist inpatient care or treatment at home may place people who cannot safely manage alone at risk when discharged 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

    Lack of a step-down community rehabilitation facility for patients unsuitable for inpatient rehabilitation but unsafe at home

    Wider context from the report

    “4. In evidence it was heard that David’s condition was such that he was not a candidate for hospital-based rehabilitation on a specialist stroke rehabilitation ward. This meant that the only available treatment option for David was to treat him at home. 5. The court was told that there is no step-down community rehabilitation facility to act as a ‘half way house’ for patients like David, if like David they are not eligible for inpatient rehabilitation, but are in reality not physically capable of keeping themselves safe when alone at home. 6. I am therefore concerned that with the current rehabilitation options available being either in a specialist hospital ward or at home, other individuals in David’s situation who are not deemed suitable for in-patient hospital, will also be placed at risk by being sent home when it is not safe to do so. ”

    Source location

    David Thomas BENDELL · 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

    Integrated Care Boards are responsible for commissioning stroke services, including rehabilitation.

    Verbatim wording from the response

    “Commissioning of stroke services, including rehabilitation, is the responsibility of Integrated Care Boards (ICB).”

    Source location

    Response from Department of Health and Social Care
    Page 1 · response
    Published 18 June 2025

    Open published response

  3. Manchester South

    AI-generated summary

    Winnie Harrop · 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

    Winnie Harrop collapsed at a care centre on 12 August 2024, was treated in hospital after sustaining facial fractures, and was discharged back to the care centre with a new oxygen requirement but without oxygen. She became drowsy and unresponsive, was readmitted on 13 August, and died in hospital on 16 August 2024. The principal concerns were unclear health and social care guidance about discharge to a care home, discharge while overly sedated, and a discharge letter that did not record the sedation level or new oxygen requirement.

    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 ensure that discharge to a non-nursing care home is appropriate for a patient's condition and care needs

    Wider context from the report

    “(1) There is no clear guidance between health and social care as to when and in what circumstances it is appropriate to send a patient back to a care home. Ms Harrop was discharged back to the care home less than 24 hours following her admission despite being overly sedated. The care home was not a nursing home. Ms Harrop’s discharge letter failed to refer to the level of sedation provided or that there was a new oxygen requirement. ”

    Source location

    Winnie Harrop · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  4. Manchester South

    AI-generated summary

    Terence 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

    Terence Davenport, who had severe dementia, was pushed by another resident at Kings Park Nursing Home on 23 May 2022, suffered a fractured neck of femur, and died at Tameside General Hospital on 24 September 2022 after declining following surgery. Concerns included his prolonged stay in an acute hospital because a suitable care placement was unavailable, and inadequate information sharing about the other resident’s aggressive behaviour, which meant risks to staff and residents were not understood.

    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 ensure resident suitability for care home placement

    Wider context from the report

    “2. The inquest was told that resident who pushed Mr Davenport was not suitable for placement at the care home where the incident happened. The care home where previous incidents had occurred was out of area. The inquest was told that lack of information sharing between two GM local authorities, the care homes involved and GMP meant that the safeguarding issue was not recognised. It was unclear if this was due to an effective information sharing protocol not existing between local authorities/care homes/GMP in Greater Manchester or it not being adhered to. However, the impact was that the risk of harm was not understood, and staff and residents were put at risk. ”

    Source location

    Terence Davenport · 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

    Send providers learning from the case on robust pre-admission risk assessments and personalised care planning that considers impacts on other residents, families and staff.

    Verbatim wording from the response

    “1) In Tameside part of our contractual and quality management oversight is around ensuring that there are robust pre-admission assessments undertaken and subsequent care planning is undertaken in line with assessment or risk. A separate communication will be sent to providers to include learning from Mr Davenport’s case, highlighting to Homes the importance of robust pre-admission risk assessments and subsequent personalised care planning around a resident’s needs whilst factoring wider impact i.e., environmental and impact on other residents, families, and staff.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 3 · response
    Published 30 October 2023

    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

    Present the case learning to Tameside care home managers and deliver a further session on discharge and transfers between community and acute settings.

    Verbatim wording from the response

    “Additionally learning from this report will be presented to Tameside Care Home Managers in December 2023; the learning will focus on sharing risk information across settings as well as completing robust pre-admission risk assessments. An additional face to face session will take place in February; this will be attended by ICFT Trust Colleagues with a focus on issues around discharge and transfer between community and acute settings.”

    Source location

    Response from Greater Manchester Integrated Care Board
    Page 4 · response
    Published 30 October 2023

    Open published response

  5. Manchester South

    AI-generated summary

    Alan Massam · 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

    Alan Massam, a resident with dementia, had repeated falls after moving to a dementia residential home and was twice admitted to hospital. After a traumatic brain bleed and rib fractures were identified, he deteriorated and died in hospital on 24 October 2019. Concerns included inadequate information-sharing between agencies, discharge without effective communication or confirmation that the care home could meet his needs, and the absence of a clear escalation process when he refused medication and fluids.

    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

    Continuation of care in a home unable to safely meet complex care needs

    Wider context from the report

    “4. Once the initial home could not manage Mr Massam and served a notice on the family there was a significant pressure to find another home that would accept him. Whilst the search was undertaken he remained in a home where staff felt they could no longer safely meet his care needs. The inquest heard that this search was exacerbated by a national shortage of suitable beds within the adult care sector for complex cases such as Mr Massam. ”

    Source location

    Alan Massam · 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

    Review safe and appropriate discharge arrangements for people with complex needs across Greater Manchester with localities.

    Verbatim wording from the response

    “For the wider Greater Manchester (GM) footprint, GMHSCP is working across the whole system to look at safe and appropriate discharges for people with complex needs. The Partnership is looking at a longer term support as part of the GM Discharge Programme and the Adult Social Care Transformation Programme. There is a programme of work underway to review this in detail and we are working with the 10 GM localities on this agenda.”

    Source location

    2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
    Page 3 · response
    Published 29 April 2021

    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

    Continue complex-needs and discharge scoping through the Learning Disabilities Complex Needs Programme.

    Verbatim wording from the response

    “Additionally there is a Learning Disabilities Complex Needs programme which has been underway for 18 months and will continue for another year. As part of this programme of work, complex needs and discharge scoping is underway.”

    Source location

    2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
    Page 3 · response
    Published 29 April 2021

    Open published response

    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 reassessment and review arrangements are relied upon to address changes in patients’ care needs and placement suitability.

    Verbatim wording from the response

    “Point 4 – suitability of placements against patient need. Our aim is to ensure that all patients are able to access the care they need, when they need it and in the environment best able to deliver the care they need. The CCG works with colleagues in the Local Authority, Adult Social Care to ensure that care needs are appropriately assessed and met. In circumstances where care needs change there is a process of re-assessment and review and once it is identified that a patient’s needs have changed families are supported in the task of identifying alternative accommodation.”

    Source location

    2021-0120-Response-from-Greater-Manchester-Health-and-Social-Care-Partnership-Redacted
    Page 3 · response
    Published 29 April 2021

    Open published response

    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

    Cases where registered-service staff cannot safely meet someone’s needs are referred to the Local Authority under safeguarding protocols.

    Verbatim wording from the response

    “The CQC have no direct remit relating to the number of suitable beds within the adult social care sector for complex cases such as Mr Massam’s. However, if the CQC receives information that staff at a registered service feel they can no longer safely meet a person’s needs we will refer the case to the Local Authority under our safeguarding protocols. The CQC will also seek assurances from the care home about how they intend to keep the person safe whilst a more suitable placement is found.”

    Source location

    2021-0120-Response-from-CQC-Redacted
    Page 6 · response
    Published 29 April 2021

    Open published response

  6. Norfolk

    AI-generated summary

    Michael Yemm · 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

    Michael Yemm had dementia and complex medical needs and was placed in a residential care home despite concerns that it was unsuitable and unsafe. He experienced several falls, including an in-patient fall that fractured his hip and required surgery, and later died in hospital. The principal concerns were the care-home placement, his discharge back to a home that had said it could not meet his needs, and the management of falls and dementia patients in hospital.

    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

    Placement of people in unsuitable and unsafe residential settings

    Wider context from the report

    “That Mr Yemm was placed into a totally unsuitable and unsafe residential setting. Shortly after his arrival, the next day, the manager contacted Mr Yemm's social worker and told them they couldn't look after him properly. Despite this he was left in this care home. ████████ wrote to the Director of Adult Social Services asking for help in finding a suitable placement and did not receive the courtesy of a reply. She was also told that after his falls that he had hairline fractures of his left hip before the fall in hospital. ”

    Source location

    Michael Yemm · 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

    Adult Social Services cannot place someone in nursing care without a health professional’s nursing needs assessment.

    Verbatim wording from the response

    “On 24 May 2020, Adult Social Services was contacted by a member of the ward staff at Langley Ward, NNUH, advising that Mr Yemm required ‘Support following hospital discharge. Unplanned admission to NNUH. Short term 24 hour residential support required while delirium resolving.’ Mr Yemm had been placed on D2A pathway 2. Norfolk County Council is not able to place people in nursing home care without a nursing needs assessment carried out by a health professional. We were advised by health professionals that nursing care was not needed at this time and residential placement was sourced at Melton House, in line with the hospital’s assessment.”

    Source location

    2021-0024-Response-from-Adult-Social-Services-Norfolk-County-Council-Redacted
    Page 2 · response
    Published 4 February 2021

    Open published response

    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

    Adult Social Care cannot source higher-level specialist placement until the CCG agrees to fund it.

    Verbatim wording from the response

    “because the nursing homes were unable to meet Mr Yemm’s level of need. Until the CCG agrees to fund a specialist neurological placement, adult social care is not able to source a placement with a higher level of care. It was not until Mrs Yemm complained that her husband’s needs were assessed for specialist provision by healthcare services.”

    Source location

    2021-0024-Response-from-Adult-Social-Services-Norfolk-County-Council-Redacted
    Page 3 · response
    Published 4 February 2021

    Open published response

    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

    The letter was escalated through the community response team and senior management, so no escalation to the Director was considered necessary.

    Verbatim wording from the response

    “A letter has been identified which Mrs Yemm shared with the community response team social worker. The community response team social worker shared this with her senior manager and at that point the meeting was called with the CCG on 2 September 2020.”

    Source location

    2021-0024-Response-from-Adult-Social-Services-Norfolk-County-Council-Redacted
    Page 2 · response
    Published 4 February 2021

    Open published response

  7. Milton Keynes

    AI-generated summary

    Siân Frances HEWITT · 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

    Siân Frances HEWITT died on 6 April 2019 at Milton Keynes University Hospital after collapsing at the Campbell Centre. The report describes failures to recognise and treat her deteriorating condition, including risks associated with pulmonary embolism, and concerns that the Campbell Centre was not an appropriate placement for people with autism and additional mental health problems.

    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 appropriate places of safety for autistic patients with additional mental health problems

    Wider context from the report

    “It would appear from the circumstances of Ms Hewitt’s death that the NHS are unable to provide a place of safety for those who are suffering from Asperger’s syndrome, or indeed other forms of autism, when they are also suffering additional mental health problems such as bipolar. The Campbell Centre in Milton Keynes was not an appropriate placement and I believe this matter should be looked at by NHS England and for more appropriate provision to be made for such patients. ”

    Source location

    Siân Frances HEWITT · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report

  8. Manchester South

    AI-generated summary

    Barry Wayne Preston · 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

    Barry Wayne Preston, who lacked capacity and lived in supported accommodation, suffered a series of falls and traumatic brain injuries before developing urosepsis associated with a catheter that was not replaced within the guidance period, followed by bronchopneumonia. The report identified concerns about inaccurate documentation, unsuitable placement and wards, inadequate coordination and ownership of care, failures to hold best interests meetings, and insufficient understanding of his lack of capacity.

    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 suitable ward placement due to capacity and flow constraints

    Wider context from the report

    “2. The inquest heard that he was kept on wards that were not suitable for him or his needs. The inquest was told that this was due to capacity and flow issues within the Royal Bolton Hospital. ”

    Source location

    Barry Wayne Preston · 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

    Review the Patient Outlier Policy with stakeholders to clarify guidance for minimising risks to patients cared for outside their specialty wards.

    Verbatim wording from the response

    “Currently, a review of the Patient Outlier Policy is being undertaken to ensure there is clear guidance in order to minimise the risks associated with patients being cared for on all wards irrespective of the speciality nature of the ward. This review is being undertaken throughout June and July 2020, engaging relevant stakeholders and led by a senior manager in consultation with the Deputy Director of Operations, Director of Quality Governance and senior Nursing and Clinical staff. The new Patient Outlier Policy will be rolled out across the Trust on 1st August 2020 provided the current COVID-19 pandemic circumstances do not delay its introduction.”

    Source location

    2020-0110-Response-from-Bolton-NHS-Foundation-Trust_Redacted.pdf
    Page 2 · response
    Published 9 June 2020

    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

    Provide the Integrated Discharge Team across all assessment wards and the Emergency Department, assigning a lead care coordinator from admission through discharge.

    Verbatim wording from the response

    “At the time of this incident the IDT did not provide a comprehensive service to inpatient assessment areas such as ward D2, operating an in-reach model which was reliant on other professionals identify those patients who had existing social care needs prior to admission to hospital. The team has been reconfigured to ensure that patients with complex health and social needs are identified through the same multi-disciplinary team process that has been in place on base ward areas. Since May 2020, all assessment wards as well as the Emergency Department are provided a full service and a lead care coordinator is assigned to oversee the coordination of the discharge planning process from admission to discharge.”

    Source location

    2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
    Page 2 · response
    Published 9 June 2020

    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

    Require wards to escalate patients with complex needs to the Integrated Discharge Team for a full multidisciplinary meeting before considering transfer of care.

    Verbatim wording from the response

    “Actions taken by Bolton Council and BNFT”

    Source location

    2020-0110-Response-from-Bolton-Council_Redacted-1.pdf
    Page 3 · response
    Published 9 June 2020

    Open published response

    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

    Local authorities, service providers and the Care Quality Commission are responsible for acting on allegations of poor care, neglect or abuse.

    Verbatim wording from the response

    “The Government is committed to preventing and reducing the risk of harm to adults in vulnerable situations. Under the Care Act 2014, we expect local authorities to ensure that the services they commission are safe, effective and of high quality. We also expect those providing the service, local authorities and the Care Quality Commission (CQC) to take swift action where anyone alleges poor care, neglect or abuse.”

    Source location

    2020-0110-Response-from-Department-of-Health-and-Social-Care.pdf
    Page 1 · response
    Published 9 June 2020

    Open published response

  9. Staffordshire South

    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 provide a care placement able to cope with complex care needs

    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

  10. Manchester South

    AI-generated summary

    John 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

    John Anthony Davies had Lewy body dementia and Parkinson’s disease and died on 23 October 2016 after deterioration following an infected pressure sore. Concerns included inadequate risk assessment when his care needs changed, poor communication and information sharing, incomplete records, lack of continuity of care, difficulties securing a suitable nursing home placement, and failures relating to pressure-relieving strategies.

    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 identify a suitable nursing home placement when the care home no longer met residents’ needs

    Wider context from the report

    “7. A suitable nursing home placement could not be identified once it had been agreed that the Care Home was no longer the best place to meet the needs of Mr Davies ”

    Source location

    John Davies · 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

    Nursing-home placement is not the District Nursing Team's responsibility, so the concern should be addressed by the CCG's Funded Nursing Care team.

    Verbatim wording from the response

    “Locating and assessing Nursing Home placements is not the responsibility of the District Nursing Team, and we respectfully request that this concern is forwarded to the Stockport Clinical Commissioning Group’s Funded Nursing Care team to be addressed.”

    Source location

    2017-0138-Response-by-Stockport-NHS-Trust
    Page 2 · response
    Published 10 July 2017

    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