Recurring concern

Inadequate drowning-risk controls during patient bathing

Pin Get email alerts Request correction

First reported 23 Oct 2013•Latest report 8 Oct 2019

Definition

What this concern includes

Includes failures of controls specifically intended to prevent drowning during patient or resident bathing, including unsuitable bath arrangements, failure to provide safer alternatives where clinically indicated, and inadequate supervision of people with known seizure or comparable risks while bathing.

Not included

  • Excludes general drowning hazards in pools, open water, rivers, roads or other settings without a patient- or resident-bathing context.
  • Excludes generic personal-hygiene, care-quality or staffing deficiencies unless they directly create an unsafe bathing or drowning-risk control failure.
  • Excludes falls, scalding or other bathing hazards where drowning risk is not the shared unsafe condition.
  • Excludes ordinary bathing preferences or the use of baths where no material patient-safety or drowning risk is identified.
Reports
2

Distinct published reports

Individual concerns
2

A report can raise multiple concerns

Date range
2013–2019

First to latest report issue date

Stated actions
3

Described in published responses

Reports over time

Reports over time

Reports about this concern issued each year.

* 2026 is projected from reports observed to 7 Sep 2026.

Most frequent recipients

Most frequent recipients

Reports about this concern sent to each recipient.

North London NHS Foundation Trust1
Pentree Lodge1

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.

  1. Cornwall and Isles of Scilly

    AI-generated summary

    Dylan Jay Henty · 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

    Dylan Jay Henty had a complex medical history including schizophrenia, a cerebral tumour, communication difficulties and seizures. He went missing after declining prescribed medication on 17 February 2018, and his body was found at Fistral beach on 21 February 2018; the cause of death was recorded as multiple injuries, with no evidence explaining the apparent fall or how he entered the sea. Concerns included an unsupervised seizure in a bath, inadequate awareness of hoarding, medication compliance, inconsistent reporting of absconding incidents, and arrangements for monitoring residents at risk of absconding.

    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 safely supervise bathing for residents with a known risk of seizure

    Wider context from the report

    “i. While it appears to have had no bearing on the circumstances of Dylan’s death, I was concerned to hear evidence of Dylan suffering a seizure in a bath while unsupervised. Similar episodes elsewhere in the country have resulted in criminal prosecutions. It is not clear to me whether reports were made to the CQC, GP and/or care coordinator. You may wish to reflect on the need for clear guidance and training to all staff on the arrangements for those residents with a known risk of seizure to take baths (as opposed to showers) where there is an obvious risk of drowning should a seizure occur. Similarly, those in management positions must be clear about the circumstances in which formal reports should be submitted to relevant bodies and you may feel there is a need to ensure these standards are rigorously checked and met. ”

    Source location

    Dylan Jay Henty · 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

    Introduce assisted or escorted bathroom use, showering preference, specialist epilepsy input, and associated seizure-safety measures for residents with diagnosed seizures.

    Verbatim wording from the response

    “1. Any resident that is known/diagnosed with seizures is to be encouraged to be assisted/escorted in the bathroom, in compliance with the relevant acts, dignity and consent from the resident. A shower is encouraged/advised over a bath and the relevant measures/training to be put in place. Care Plans and Risk Assessments to be done with the support and advice of the Specialist Epilepsy Nurse. All relevant physical illnesses where an ambulance/out of hours doctor are called, accidents or hospital admissions are reported to the relevant bodies i.e. Care co-ordinators. The GP has access to this information via R.I.O. A report is also sent to the GP from the relevant bodies.”

    Source location

    2019-0334-Response-by-Pentree-Lodge-Care-Home
    Page 1 · response
    Published 10 November 2019

    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

    Review all residents’ physical health and seizure histories.

    Verbatim wording from the response

    “2. Since the inquest management of the home have reviewed all residents physical health. Management have picked up that another resident who has a history of seizures, she hasn’t had a seizure since being in the care home for over 5 years but has not been reviewed by any health professional for at least 10 years regarding her history of seizures. This is now being reviewed by ████████ When confirmation of this is sort the home will review its Risk Assessments and Care Plans and put in place the relevant measures surrounding bathing and showering, training on this specialist area will be undertaken by all staff.”

    Source location

    2019-0334-Response-by-Pentree-Lodge-Care-Home
    Page 1 · response
    Published 10 November 2019

    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

    Review seizure-related risk assessments and care plans, implement bathing and showering measures, and provide specialist training after receiving clinical confirmation.

    Verbatim wording from the response

    “2. Since the inquest management of the home have reviewed all residents physical health. Management have picked up that another resident who has a history of seizures, she hasn’t had a seizure since being in the care home for over 5 years but has not been reviewed by any health professional for at least 10 years regarding her history of seizures. This is now being reviewed by ████████ When confirmation of this is sort the home will review its Risk Assessments and Care Plans and put in place the relevant measures surrounding bathing and showering, training on this specialist area will be undertaken by all staff.”

    Source location

    2019-0334-Response-by-Pentree-Lodge-Care-Home
    Page 1 · response
    Published 10 November 2019

    Open published response

  2. Inner North London

    AI-generated summary

    John Frank Henry LANSDOWNE · 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 Frank Henry Lansdowne, who had schizophrenia and a history of serious suicide attempts, was admitted to St Pancras Hospital under section 3 of the Mental Health Act after talking about taking his life. He was found submerged in a bath on 18 May 2012 and died shortly afterwards. Concerns included unclear observation timings, an unrecovered observation sheet, inconsistent staff understanding of observations while a patient was bathing, and the use of baths rather than walk-in showers.

    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

    Possible drowning hazard associated with patient bathing in baths

    Wider context from the report

    “4. Mr Lansdowne died in the bath, it is possible as a result of drowning. Mr Lansdowne’s family explained at inquest that in other hospitals where he had been treated, only walk in showers are used. ”

    Source location

    John Frank Henry LANSDOWNE · Prevention of Future Deaths report
    Page 2 · concerns

    Open source report
Back to top

Data last updated 7 September 2026