Recipient

Bank Close House

First report 13 Jan 2026•Latest report 13 Jan 2026

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 5

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

5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Bank Close House linked to the concerns in each report. Select any concern, action or position to view the source wording.

13 Jan2026
Derby and Derbyshire
Concerns raised2
1. Failure of care home staff to perform blood sugar pin prick testing for ill residents with Type 2 Diabetes
2. Failure to conduct formal handovers between shifts
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Instruct staff to request immediate blood glucose testing from external professionals when diabetic residents show illness or other concerning health changes.
  Stated completed
2. Action
  Strengthen documentation requirements so verbal handover information is consistently and accurately recorded.
  Stated completed
3. Action
  Continue monitoring and reviewing arrangements until the blood glucose testing training pathway and responsibilities are formally confirmed.
  Stated in progress
Respondent positions 3
1. Position
  The home disputes that care staff should undertake blood glucose testing, relying on consistent contrary guidance from external healthcare professionals.
  Disputes the concern
1. Position
  The home cannot implement staff blood glucose testing until external professionals confirm training, competency requirements and clinical governance arrangements.
  Unable to act
2. Position
  Until care staff are trained and assessed as competent, external healthcare professionals will undertake blood glucose testing for diabetic residents.
  Redirects responsibility
AI-generated summary

Peter William THOMPSON · 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

Peter William Thompson, who had Type 2 Diabetes and had moved into residential care after worsening mobility, became ill with a urinary tract infection, reduced food and fluid intake, swallowing difficulties and refusal of medication. His blood sugar levels were not tested until paramedics attended on 5 March 2025, by which time he had developed Hyperglycaemic Hyperosmolar State and severe kidney damage; he died in hospital on 9 March 2025. The principal concerns were the absence of blood sugar testing by care home staff and the lack of formal handovers between shifts, which could delay escalation of a resident’s deteriorating condition.

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 Bank Close House; that does not assign responsibility.
PFD Monitor interpretation
Failure of care home staff to perform blood sugar pin prick testing for ill residents with Type 2 Diabetes
Wider context from the report
“1. Worsening blood sugar levels in a resident with Type 2 Diabetes can be fatal. Illnesses including infection can cause the progressive condition of Hyperglycaemic Hyperosmolar State. This is what happened with Peter Thompson. No one tested his blood sugar levels until the paramedics attended on 5 March 2025. By this time his condition was so severe his prognosis was poor and he did not recover despite treatment. I heard evidence that the earlier treatment is started the better the prognosis. I heard evidence from members of the Ageing Well Team and the Community Nurse that there was an expectation that Care Home staff were carrying out the blood sugar pin prick test. The former manager of the home said that Care Home staff do not do this and do not have the equipment to do this. This test is not complex. It is a test that a resident or a carer would do in their own home. It would form part of a baseline observation for a Type 2 Diabetic patinet who was ill and assist with decision on need to escalate. The continued absence of this test being done by care home staff gives cause for concern that there is a risk that a future death could occur. ”
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 Bank Close House; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct formal handovers between shifts
Wider context from the report
“2. I heard evidence from the former manager that handovers between shifts do not take place. That staff should look in an individual residents' records. Records do not provide a complete picture of a residents condition and in particular details of staff's ongoing concerns. The priority of the continuing concern about Peter's deterioration does not appear from the records to have been handed over between shifts. To not have a formal handover at the end and start of a shift gives cause for concern that there is a risk to future death. That delays are caused in escalating a resident's condition. ”
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
Instruct staff to request immediate blood glucose testing from external professionals when diabetic residents show illness or other concerning health changes.

Verbatim wording from the response
“As an interim measure, staff have been instructed that any concerns about a diabetic resident’s health must include a request for a blood glucose test from external healthcare professionals until training and competencies are completed by care staff.”

Source location
Response from Bank Close House Residential Care Home
Page 2 · response
Published 20 January 2026
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
Strengthen documentation requirements so verbal handover information is consistently and accurately recorded.

Verbatim wording from the response
“We acknowledge the coroner’s concern that the records reviewed during the inquest did not fully reflect the level of discussion or the priority of concerns during handover. In response, we have strengthened documentation expectations to ensure that all verbal handover information is consistently and accurately recorded.”

Source location
Response from Bank Close House Residential Care Home
Page 1 · response
Published 20 January 2026
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
Continue monitoring and reviewing arrangements until the blood glucose testing training pathway and responsibilities are formally confirmed.

Verbatim wording from the response
“Further monitoring and review will continue until the training pathway and responsibilities are formally confirmed.”

Source location
Response from Bank Close House Residential Care Home
Page 2 · response
Published 20 January 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The home disputes that care staff should undertake blood glucose testing, relying on consistent contrary guidance from external healthcare professionals.

Verbatim wording from the response
“The coroner’s report states that Bank Close House should be carrying out blood glucose testing for diabetic residents. Historically, the home has been advised by both the Ageing Well Team and the GP Practice Advanced Nurse Practitioner that care home staff should not undertake blood glucose testing. This guidance has been consistent and shaped our practice, please see attached care plans with entries added in with instructions from ageing well team.”

Source location
Response from Bank Close House Residential Care Home
Page 1 · response
Published 20 January 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
The home cannot implement staff blood glucose testing until external professionals confirm training, competency requirements and clinical governance arrangements.

Verbatim wording from the response
“• They remain uncertain about who will be responsible for delivering the required training and competency assessments for care home staff.”

Source location
Response from Bank Close House Residential Care Home
Page 1 · response
Published 20 January 2026
Open published response
Source evidence

How this respondent position was interpreted

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

PFD Monitor interpretation
Until care staff are trained and assessed as competent, external healthcare professionals will undertake blood glucose testing for diabetic residents.

Verbatim wording from the response
“Until staff are trained and signed off as competent, all concerns regarding a diabetic resident’s health will continue to be escalated to external professionals, who will carry out blood glucose testing as needed.”

Source location
Response from Bank Close House Residential Care Home
Page 2 · response
Published 20 January 2026
Open published response

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 raised2

Failure of care home staff to perform blood sugar pin prick testing for ill residents with Type 2 Diabetes

Failure to conduct formal handovers between shifts

Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised.3

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.3

Actions described in response 3

Respondent positions 3