Recipient

Adbolton Hall

First report 26 Mar 2018•Latest report 26 Mar 2018

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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 Adbolton Hall linked to the concerns in each report. Select any concern, action or position to view the source wording.

26 Mar2018
Nottinghamshire
Concerns raised10
1. Failure to seek Dementia Outreach Team assistance for deteriorating blood glucose and insulin compliance
2. Failure to seek medical assistance when insulin is refused over an extended period
3. Failure to recognise an incorrect blood glucose reading
1. Inability to accurately obtain blood glucose levels
2. Failure to alert management to prolonged insulin refusal
3. Failure to administer Lucozade safely when blood glucose levels are unavailable or critically high
4. Inadequate completion of nursing home records
5. Failure to seek urgent GP attention during attendance at the home
6. Failure to make staff available for pre-arranged Diabetes Nurse appointments
7. Failure to recognise and seek help for a deteriorating condition
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Joan Osborne · 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

Joan Osborne, who had diabetes and advanced dementia, died on 25 August 2017 after repeated difficulties obtaining her blood glucose levels and administering her insulin. The concerns included failures by nursing home staff to seek medical assistance or escalate her missed insulin, inadequate records, failure to recognise her deteriorating condition, and inaccurate blood glucose measurement and treatment on 22 August 2017.

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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek Dementia Outreach Team assistance for deteriorating blood glucose and insulin compliance
Wider context from the report
“(1) The nursing home staff did not seek assistance from the Dementia Outreach Team when Mrs Osborne’s compliance with her blood glucose levels and insulin prescription deteriorated at the end of 2016 onwards. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek medical assistance when insulin is refused over an extended period
Wider context from the report
“(3) The nursing home staff did not seek medical assistance for Mrs Osborne when she refused to have her insulin prescription over an extended period, on two separate occasions, leading to her hospitalisation on 12.08.2017 and 22.08.2017. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise an incorrect blood glucose reading
Wider context from the report
“(8) A member of staff at the care home was unable to accurately obtain Mrs Osborne’s blood glucose level on 22.08.2017 when asked by the GP and did not recognise that the reading was incorrect. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Inability to accurately obtain blood glucose levels
Wider context from the report
“(8) A member of staff at the care home was unable to accurately obtain Mrs Osborne’s blood glucose level on 22.08.2017 when asked by the GP and did not recognise that the reading was incorrect. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to alert management to prolonged insulin refusal
Wider context from the report
“(4) The nursing home staff did not alert anyone in the management team to the fact that Mrs Osborne had refused to have her insulin prescription for a period of 3 days prior to her hospitalisation on 22.08.2017. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to administer Lucozade safely when blood glucose levels are unavailable or critically high
Wider context from the report
“(7) Mrs Osborne was incorrectly given Lucozade on the morning of 22.08.2017 at a point when her blood glucose levels had not been obtained, and were ‘HI’. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Inadequate completion of nursing home records
Wider context from the report
“(5) The nursing home records in respect of Mrs Osborne were inadequately completed. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek urgent GP attention during attendance at the home
Wider context from the report
“(6) The nursing home staff did not recognise the need, nor seek help, for Mrs Osborne’s deteriorating condition on 22.08.2017 and did not seek the urgent attention of her GP upon his usual attendance at the home on that date. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to make staff available for pre-arranged Diabetes Nurse appointments
Wider context from the report
“(2) The nursing home did not make any members of staff available for the pre-arranged appointment with the Diabetes Nurse on 28.11.2017 resulting in a missed opportunity to seek assistance with Mrs Osborne’s compliance. ”
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 Adbolton Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise and seek help for a deteriorating condition
Wider context from the report
“(6) The nursing home staff did not recognise the need, nor seek help, for Mrs Osborne’s deteriorating condition on 22.08.2017 and did not seek the urgent attention of her GP upon his usual attendance at the home on that date. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised10

Failure to seek Dementia Outreach Team assistance for deteriorating blood glucose and insulin compliance

Failure to seek medical assistance when insulin is refused over an extended period

Failure to recognise an incorrect blood glucose reading

Inability to accurately obtain blood glucose levels

Failure to alert management to prolonged insulin refusal

Failure to administer Lucozade safely when blood glucose levels are unavailable or critically high

Inadequate completion of nursing home records

Failure to seek urgent GP attention during attendance at the home

Failure to make staff available for pre-arranged Diabetes Nurse appointments

Failure to recognise and seek help for a deteriorating condition