Acorn Lodge Care Centre

Private and voluntary organisations · Nursing home

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First report 18 Apr 2016•Latest report 18 Apr 2016

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

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

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
4

Described in responses

Concerns and recipient responses

Statements from Acorn Lodge Care Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Doreen Mattinson · 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

    Doreen Mattinson, an 80-year-old resident of Acorn Care Home with dementia and other comorbidities, deteriorated rapidly with laboured breathing on 12 November 2015. Concerns were raised about the administration of oxygen, including the flow rate, her supine position, and the absence of evidence of training for the registered nurse who administered it.

    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 Acorn Lodge Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to administer the required oxygen flow

    Wider context from the report

    “(1) The London Ambulance Service attended Mrs Mattinson on 12 November 2015 and made a Safeguarding Report relating to the use of the oxygen. It had been reported that Mrs Mattinson had been lying supine on the bed saturating at 84% and struggling to breath. The oxygen could not be heard to be running and it was noted that only 1 litre was running when this should have been a15 litre flow with the mask applied. ”
    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 Acorn Lodge Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of recognition of the oxygen level required in an emergency situation

    Wider context from the report

    “(2)There was no recognition by the Clinical Manager or those present on 12 November 2015 of the level of oxygen to be used in an emergency situation or as to the importance of sitting the patient in an upright position. ”
    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 Acorn Lodge Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise the importance of sitting the patient in an upright position

    Wider context from the report

    “(2)There was no recognition by the Clinical Manager or those present on 12 November 2015 of the level of oxygen to be used in an emergency situation or as to the importance of sitting the patient in an upright position. ”
    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 Acorn Lodge Care Centre; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training of the Clinical Manager to administer oxygen

    Wider context from the report

    “(3)There was no evidence of training of the Clinical Manager, who was a registered nurse and the only member of staff on the residential unit on that day who would be expected to administer oxygen. ”
    Open source report
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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