Aden Court Care Home

Private and voluntary organisations · Residential care home

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First report 23 Dec 2021•Latest report 23 Dec 2021

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

Concerns and recipient responses

Statements from Aden Court Care Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

23 Dec2021
West Yorkshire (Western)
Concerns raised16
1. Inadequate care plan protocols
2. Inadequate note taking
3. Inadequate protocols for initial wound assessment
1. Insufficient staff training for visual checks at handover
2. Inadequate protocols for return from hospital forms
3. Failure of protocols to ensure compliance with care plans
4. Inadequate provision of crash and sensor mats
5. Inadequate documentation of crash and sensor mat use
6. Insufficient staff training for communications at handover
7. Inadequate documentation of visual checks on residents in their rooms
8. Failure to appropriately deal with hospital correspondence concerning patient care
9. Inadequate wound management protocols
10. Inadequate protocols for completion of admission documentation
11. Failure to report accidents when they take place
12. Inadequate body map protocols
13. Inadequate protocols for consent to medical treatment forms
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Dilys Greta Etchells · 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

Dilys Greta Etchells was found after an unwitnessed fall at her nursing home, later diagnosed with fractures of the left tibia and fibula, and subsequently developed pressure ulcers before dying in hospital on 2 July 2021. The report identified concerns about the absence or documentation of fall-prevention measures, delayed medical referral, inadequate care documentation, handover communications, and wound-management procedures.

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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate care plan protocols
Wider context from the report
“• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate note taking
Wider context from the report
“• To review existing practices with regard to the adequacy of note taking and to consider protocols to ensure compliance with care plans. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate protocols for initial wound assessment
Wider context from the report
“• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staff training for visual checks at handover
Wider context from the report
“• To give consideration to staff training with respect to visual checks at handover to ensure resident’s needs are met in accord with the care plans. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate protocols for return from hospital forms
Wider context from the report
“• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of protocols to ensure compliance with care plans
Wider context from the report
“• To review existing practices with regard to the adequacy of note taking and to consider protocols to ensure compliance with care plans. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate provision of crash and sensor mats
Wider context from the report
“• To review and reconsider the adequacy of the provision of crash and sensor mats and the means for properly documenting their use and reporting accidents when they take place. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate documentation of crash and sensor mat use
Wider context from the report
“• To review and reconsider the adequacy of the provision of crash and sensor mats and the means for properly documenting their use and reporting accidents when they take place. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Insufficient staff training for communications at handover
Wider context from the report
“• To consider the necessity of staff training with regard to communications at handover and dealing with correspondence received from the hospital with regard to patient care. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate documentation of visual checks on residents in their rooms
Wider context from the report
“• Consider the adequacy of the supporting documentation with regard to visual checks on residents in their rooms. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to appropriately deal with hospital correspondence concerning patient care
Wider context from the report
“• To consider the necessity of staff training with regard to communications at handover and dealing with correspondence received from the hospital with regard to patient care. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate wound management protocols
Wider context from the report
“• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate protocols for completion of admission documentation
Wider context from the report
“• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to report accidents when they take place
Wider context from the report
“• To review and reconsider the adequacy of the provision of crash and sensor mats and the means for properly documenting their use and reporting accidents when they take place. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate body map protocols
Wider context from the report
“• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. ”
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 Aden Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Inadequate protocols for consent to medical treatment forms
Wider context from the report
“• To review existing protocols governing wound management, completion of admission documentation, care plans, initial wound assessment, body maps, consent to medical treatment form and the return from hospital form. ”
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 raised16

Inadequate care plan protocols

Inadequate note taking

Inadequate protocols for initial wound assessment

Insufficient staff training for visual checks at handover

Inadequate protocols for return from hospital forms

Failure of protocols to ensure compliance with care plans

Inadequate provision of crash and sensor mats

Inadequate documentation of crash and sensor mat use

Insufficient staff training for communications at handover

Inadequate documentation of visual checks on residents in their rooms

Failure to appropriately deal with hospital correspondence concerning patient care

Inadequate wound management protocols

Inadequate protocols for completion of admission documentation

Failure to report accidents when they take place

Inadequate body map protocols

Inadequate protocols for consent to medical treatment forms