Recipient

Amberley Hall Care Home

First report 27 Oct 2023•Latest report 27 Oct 2023

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

27 Oct2023
Norfolk
Concerns raised8
1. Failure to record observations in Care Records
2. Failure to identify gaps in records through routine management oversight
3. Failure to communicate NEWS2 scores to the 111 call taker
1. Failure to take observations hourly
2. Incomplete food and fluid charting
3. Failure to call emergency services for a NEWS2 score of 9
4. Failure to take action following a patient's death
5. Insufficient food and fluid intake
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

Geoffrey Alan WHATLING · 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

Geoffrey Alan Whatling entered Amberley Hall Care Home for rehabilitation and later became unwell, with deteriorating NEWS2 scores leading to hospital admission on 10 April 2023. He died on 26 April 2023, with the medical cause of death recorded as infective exacerbation of chronic obstructive pulmonary disease, with frailty and old age. Concerns included incomplete food and fluid records, failures to call emergency services when required, inadequate observation frequency, and gaps in care-record documentation and follow-up.

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 Amberley Hall Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to record observations in Care Records
Wider context from the report
“5. Some of Mr Whatling’s observations were recorded on a piece of paper and were not logged in his Care Records ”
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 Amberley Hall Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to identify gaps in records through routine management oversight
Wider context from the report
“6. The Manager only became aware of gaps in the records following concerns raised by the family. ”
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 Amberley Hall Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to communicate NEWS2 scores to the 111 call taker
Wider context from the report
“3. The evidence so far revealed is that 111 call taker was not made aware Mr Whatling had scored NEWS2 7. ”
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 Amberley Hall Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to take observations hourly
Wider context from the report
“4. Mr Whatling’s observations were not taken hourly as required. ”
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 Amberley Hall Care Home; that does not assign responsibility.
PFD Monitor interpretation
Incomplete food and fluid charting
Wider context from the report
“1. Mr Whatling was not eating and drinking very much. A food and fluid chart was not fully 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 Amberley Hall Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to call emergency services for a NEWS2 score of 9
Wider context from the report
“2. Emergency services were not called on 8 April 2023 when Mr Whatling scored NEWS2 9 as required. ”
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 Amberley Hall Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to take action following a patient's death
Wider context from the report
“7. There is no evidence that any action has been taken following Mr Whatling’s death. ”
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 Amberley Hall Care Home; that does not assign responsibility.
PFD Monitor interpretation
Insufficient food and fluid intake
Wider context from the report
“1. Mr Whatling was not eating and drinking very much. A food and fluid chart was not fully completed. ”
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 raised8

Failure to record observations in Care Records

Failure to identify gaps in records through routine management oversight

Failure to communicate NEWS2 scores to the 111 call taker

Failure to take observations hourly

Incomplete food and fluid charting

Failure to call emergency services for a NEWS2 score of 9

Failure to take action following a patient's death

Insufficient food and fluid intake