Recipient

Aria Healthcare Group Ltd

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First report 29 Mar 2016•Latest report 29 Mar 2016

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. 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
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
12

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.

100%published responses found
12stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Aria Healthcare Group Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to “CARING HOMES HEALTHCARE GROUP LIMITED”, a former name of Aria Healthcare Group Ltd.

    Norfolk

    AI-generated summary

    PAMELA JOYCE THURSTON · 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

    Pamela Joyce Thurston, a resident of Cedar Care Home with Alzheimer's dementia, choked on toast after being given food following an approximately 17-hour period without eating and without direct supervision. She developed bronchopneumonia and died in hospital two days later. The substantive concerns included her not being given breakfast, the lack of direct supervision while eating, and the response to the choking incident.

    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 Aria Healthcare Group Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide direct supervision during eating for residents who require it

    Wider context from the report

    “Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton. She suffered from Alzheimer's dementia and required prompting in order to eat meals and also supervision in doing so. Approximately two weeks prior to her death, Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out. This was reported to the Care Home Manager and thereafter she was given prunes with stones removed. Her care plan was not altered, but a note was made for the chef to this effect. The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately 5pm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to day shift. On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast. This was given to Mrs Thurston who proceeded to eat the toast so quickly that it became stuck in her airway which caused her to choke. Attempts were made to remove the toast when the attention of the staff was drawn to this by another resident. The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in eating the toast. The nurse was unable to remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics. Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 July 2015 in hospital. It appears that Mrs Thurston ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours. When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later. ”
    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 Aria Healthcare Group Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to update care plans following identified choking risks

    Wider context from the report

    “Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton. She suffered from Alzheimer's dementia and required prompting in order to eat meals and also supervision in doing so. Approximately two weeks prior to her death, Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out. This was reported to the Care Home Manager and thereafter she was given prunes with stones removed. Her care plan was not altered, but a note was made for the chef to this effect. The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately 5pm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to day shift. On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast. This was given to Mrs Thurston who proceeded to eat the toast so quickly that it became stuck in her airway which caused her to choke. Attempts were made to remove the toast when the attention of the staff was drawn to this by another resident. The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in eating the toast. The nurse was unable to remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics. Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 July 2015 in hospital. It appears that Mrs Thurston ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours. When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later. ”
    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 Aria Healthcare Group Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to verify that residents have received their meals

    Wider context from the report

    “Mrs Pamela Thurston was a resident at Cedar Care Home in Yelverton. She suffered from Alzheimer's dementia and required prompting in order to eat meals and also supervision in doing so. Approximately two weeks prior to her death, Mrs Thurston was found to have stored prune stones in her mouth and had to be encouraged to spit them out. This was reported to the Care Home Manager and thereafter she was given prunes with stones removed. Her care plan was not altered, but a note was made for the chef to this effect. The Care Home procedure for checking that residents had been fed at mealtimes was that the chef would tick off the residents on a list kept in the kitchen. The residents were given their evening meal at approximately 5pm, and breakfasts were served from approximately 8am onwards following the staff handover at that time from night to day shift. On the morning of 5 July 2015, Mrs Thurston had awoken early as was her tendency, and was sitting in the care home conservatory. At approximately 11am, one of the staff became aware that she had not been given any breakfast and a decision was made to give her some toast. This was given to Mrs Thurston who proceeded to eat the toast so quickly that it became stuck in her airway which caused her to choke. Attempts were made to remove the toast when the attention of the staff was drawn to this by another resident. The nurse on duty was in a position to observe Mrs Thurston, but did not directly supervise her in eating the toast. The nurse was unable to remove the toast from Mrs Thurston's airway. Her subsequent attempts at CPR were unsuccessful, and heart rhythm was not restored until the arrival of paramedics. Mrs Thurston developed bronchopneumonia as a consequence of the choking incident, and subsequently died on 7 July 2015 in hospital. It appears that Mrs Thurston ate the toast she had been given too quickly as a consequence of being hungry, having had no food since the previous evening approximately between 5pm and 6pm, being a period of around 17 hours. When given the toast, she was left to eat this without direct supervision. She choked on the toast, and died in hospital two days later. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Record meal-service times and provide documented direct observation after missed meals or gaps of eight hours or more.

    Verbatim wording from the response

    “5. Ensure a tick list is in the kitchen area which documents the time a service user is served with a meal in the Home. Where it is noticed that a significant period of time has passed between meals for a service user (eight hours or over), or where a service user has missed a meal, direct observations of the service user should be maintained whilst the service user is eating their meal or snack. The person in charge must designate a member of staff to undertake the observation and this should be documented in the service users notes.”

    Source location

    Thurston-Response
    Page 2 · response
    Published 29 March 2016

    Open published response

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Record food served, service times and amounts consumed for residents with compromised nutritional intake.

    Verbatim wording from the response

    “6. Where a service user has compromised nutritional intake, a record of food served, the time and the amount taken should be maintained as is usual procedure.”

    Source location

    Thurston-Response
    Page 2 · response
    Published 29 March 2016

    Open published response
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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

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

How actions were described at the time

This respondent
17%8%75%
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