Recipient

Acer Mews

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First report 5 Dec 2025•Latest report 5 Dec 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Acer Mews linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Alan Paul Peet · 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 Paul Peet, who was quadriplegic following an accidental fall, was admitted to hospital after his condition deteriorated at Acer Mews Care Home on 26 July 2025. He was found to be septic, possibly due to bronchopneumonia, and died at Tameside General Hospital on 28 July 2025. Concerns included inadequate observation and record-keeping, lack of clear management oversight of tracheostomy-trained nursing cover, and agency staff lacking access to electronic systems.

    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. The report was sent to Acer Mews; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of management oversight and safeguards for nursing staff allocation decisions

    Wider context from the report

    “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube. The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants. On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit. It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising. The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries. Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Acer Mews; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide agency nurses with individual login rights to electronic care and medication systems

    Wider context from the report

    “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube. The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants. On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit. It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising. The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries. Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Acer Mews; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain complete and comprehensible care notes

    Wider context from the report

    “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube. The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants. On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit. It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising. The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries. Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point. ”
    Open source report

    Source evidence

    How this individual concern was interpreted

    PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Acer Mews; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure tracheostomy-trained nursing cover for residents requiring tracheostomy support

    Wider context from the report

    “Mr Peet according to the evidence heard at the inquest was placed at Acer Mews Care Home. His care according to information from his family was provided at a cost of approximately £10,000 a week. This was because he required 24/7 one to one care in a nursing home setting because of the extent of his needs including management of his tracheostomy tube. The inquest heard that at the home there were 2 units, with one registered nurse allocated to each unit. The remainder of the staff were Health Care Assistants. On the day of his admission to hospital the nurse trained in tracheostomy management decided not to cover the unit Mr Peet was in even though there were 3 patients requiring support with tracheostomies on that unit. Instead, they chose to work on the other unit. This left a nurse untrained in tracheostomies on that unit. It was unclear why there was no management oversight of this decision and what steps were in place at the time to avoid such a situation arising. The inquest was also told that the agency nurse used on the day did not have log in rights to the electronic systems in place at the home including the medication system. It was indicated that the manager at the time was aware of this and that it was likely that the nurse could as a consequence only make entries under the details of the other nurse. During the course of the inquest, it was difficult to unpick who had made certain entries. Even though Mr Peet was on one-to-one care and those involved could have no other residents to write up during the time they were caring for him the overall quality of the notes was extremely poor. Entries were limited and it was impossible to fully understand from the notes what had been observed and what had happened and at what point. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026