27 Oct 2023 Geoffrey Alan WHATLING · Prevention of Future Deaths report Norfolk
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Concerns raised 8 Failure to record observations in Care Records View source Failure to identify gaps in records through routine management oversight View source Failure to communicate NEWS2 scores to the 111 call taker View source Failure to take observations hourly View source Incomplete food and fluid charting View source Failure to call emergency services for a NEWS2 score of 9 View source Failure to take action following a patient's death View source Insufficient food and fluid intake View source See 5 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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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.
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× 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 Athena Care Homes (UK) Limited; 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 Athena Care Homes (UK) Limited; 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 Athena Care Homes (UK) Limited; 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 Athena Care Homes (UK) Limited; 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 Athena Care Homes (UK) Limited; 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 Athena Care Homes (UK) Limited; 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 Athena Care Homes (UK) Limited; 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 Athena Care Homes (UK) Limited; 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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations