Concerns raised 6 Failure to complete and audit improvements to pressure sore prevention and management View source Failure to complete early and appropriate pressure sore risk assessment View source Failure to provide appropriate pressure sore treatment View source Failure to use pressure sore preventative measures View source Failure to monitor residents' skin condition for pressure sores View source Failure to record pressure sore risk, skin monitoring and treatment information View source See 3 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 19
Action
Appoint a Regional Manager to provide increased management oversight.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Introduce and embed the Enable electronic records and case-management system for care documentation and oversight.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Provide dedicated management and clinical support, daily meetings and escalation of changes in residents’ clinical status through electronic notifications.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Operate daily, monthly and bi-monthly audits of care documentation, skin integrity, risk assessments, equipment, interventions and follow-up actions.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Provide weekly Clinical Development Nurse reviews of skin-integrity risks, care plans, wound assessments, categorisation, referrals and clinical concerns.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Conduct operational observations, monitoring visits and staff supervisions addressing equipment, moving and handling, and regular repositioning.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Deliver staff training, supervision, knowledge checks and refresher sessions on pressure-area care, tissue-viability policy, risk assessment, prevention, skin monitoring, wound treatment and record keeping.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Train staff on dynamic-air-mattress settings, regular equipment checks and obtaining replacement mattresses outside hours.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Deliver reflective sessions and disseminate inquest learning to Home staff on pressure-injury risk, prevention, treatment and documentation.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Train staff and maintenance personnel to set, check and replace dynamic air mattresses appropriately, including accessing out-of-hours replacements.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Review and update residents’ assessments, risk assessments and care plans monthly through the Resident of the Day process.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Implement and embed the Enable electronic records and case-management system.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Hold bi-weekly clinical governance meetings to review high-risk residents, tissue-viability issues, referrals and clinical deterioration.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Conduct observations, staff supervisions and equipment-use support covering repositioning, moving and handling, mattresses and pressure-relieving equipment.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Carry out monthly skin-integrity audits and additional Regional Manager reviews of high-risk residents’ interventions, equipment, care plans and Waterlow scores.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Deliver pressure-area, wound-management, tissue-viability, risk-assessment, prevention, skin-monitoring and record-keeping training with supervision and knowledge checks for staff.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Maintain electronic notifications and management oversight of clinical-status changes, wound categorisation, care planning and treatment regimes.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Carry out daily care-record sampling and monthly documentation audits, with management follow-up of identified actions.
Stated completedThe respondent said that this action was complete when they made their response on 23 December 2025. View source
Action
Provide ongoing weekly Clinical Development Nurse reviews of skin-integrity risks, wound assessments, categorisation and care plans.
Stated in progressThe respondent said that this action was in progress when they made their response on 23 December 2025. View source See 16 more actions
×
AI-generated summary
Ramona Doreen Harbott · 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
Ramona Doreen Harbott was admitted to Windmill Manor Care Home with very limited mobility and a high risk of pressure sores. She developed serious sacral and heel pressure sores, and later died in hospital from sepsis having contracted pneumonia. Concerns included inadequate repositioning, skin monitoring, pressure sore treatment and record keeping, with improvements still ongoing and not yet completed and audited.
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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and audit improvements to pressure sore prevention and management
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited .
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete early and appropriate pressure sore risk assessment
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk , use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide appropriate pressure sore treatment
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to use pressure sore preventative measures
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff . Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore . Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures , skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor residents' skin condition for pressure sores
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring , pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record pressure sore risk, skin monitoring and treatment information
Wider context from the report “a. The evidence heard by the court indicated that though the care home had policies and guidance for the prevention and management of bed sores that was not followed by on-site care or nursing staff. Although at high risk of pressure sores Mrs Harbott was not regularly repositioned until she had developed a sacral sore. Her skin condition was not monitored and recorded to the extent that though the sore was apparently being treated, it had become an unstageable necrotic wound by the time she was taken to hospital. The serious pressure sore on the right heel was not documented until it was seen on 23 January 2025 although it was likely well established for at least a week.
b. The coroner acknowledges that Barchester Health Care have since this death and the inquest hearing in November 2025 commenced an action plan of improvements including greater regional management oversight however the coroner remains concerned that the matters identified at the inquest regarding issues surrounding early and appropriate assessment of risk, use of preventative measures, skin monitoring, pressure sore treatment and record keeping are the subject of ongoing improvement which has yet to be completed and audited.
” 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 Appoint a Regional Manager to provide increased management oversight.
Verbatim wording from the response “Whilst some of the actions are completed such as replacement of the General Manager, appointment of a Regional Manager and dismissal of the Deputy Manager, other actions are necessarily part of day-to-day documentation and process which will remain embedded and ongoing to ensure a robust approach to the planning and management of the needs of our residents.” Source location Response from Barchester Healthcare Ltd
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 Introduce and embed the Enable electronic records and case-management system for care documentation and oversight.
Verbatim wording from the response “• Introduction and embedding of electronic records and case management system ‘Enable’.” Source location Response from Barchester Healthcare Ltd
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 Provide dedicated management and clinical support, daily meetings and escalation of changes in residents’ clinical status through electronic notifications.
Verbatim wording from the response “(iii) The General Manager at Windmill Manor Care Home has been provided with dedicated support from the Managing and Regional Directors and the Clinical Development Nurse during the recent period of change at the home. When changes to a resident’s clinical status are identified, including deterioration to skin integrity, these are added to the online systems which immediately notifies the Clinical” Source location Response from Barchester Healthcare Ltd
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 Operate daily, monthly and bi-monthly audits of care documentation, skin integrity, risk assessments, equipment, interventions and follow-up actions.
Verbatim wording from the response “iii. The General Manager daily walk around of the Home includes ad hoc sampling of resident care records and supporting documentation. This audit tool also directs the General Manager to approach and question both residents, families and staff to identify any concerns. Any actions identified are discussed at the daily stand-up meeting and then carried forward to the next meeting, to ensure review of completion.” Source location Response from Barchester Healthcare Ltd
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 Provide weekly Clinical Development Nurse reviews of skin-integrity risks, care plans, wound assessments, categorisation, referrals and clinical concerns.
Verbatim wording from the response “• The Clinical Development Nurse now visits the Home on a weekly basis to review the approach to the management of risk to skin integrity and care and treatment plans in place where skin damage has been identified for any resident. She checks that wound assessment and categorisation is being completed correctly with review of wounds by staff in person supported by photographs. She attends the daily stand-up meeting during her visit to follow up on assessments and referrals and any clinical concerns. She is also available for advice and assistance to all staff outside these visits and can review concerns on an ‘as needed’ basis. She has reported an improvement overall in the approach of staff and their recognition of the importance of early interventions and comprehensive treatment plans.” Source location Response from Barchester Healthcare Ltd
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 Conduct operational observations, monitoring visits and staff supervisions addressing equipment, moving and handling, and regular repositioning.
Verbatim wording from the response “• The Regional Operational Trainer and Clinical Development Nurse have attended the Home on several occasions to carry out observations and monitoring and to identify any further areas for improvement for the clinical team. Visits took place on 7, 10, 15 and 22 October. On 15 October 2025 the Clinical Development Nurse attended the Home to review equipment used by staff to support resident care needs. A group session with staff was held to discuss availability of equipment, appropriate use and processes and procedures to assess need and request equipment including pressure relieving mattresses. During an observation visit on 22 October 2025 there was a focus on Moving and Handling techniques used by staff at the Home. No concerns” Source location Response from Barchester Healthcare Ltd
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 Deliver staff training, supervision, knowledge checks and refresher sessions on pressure-area care, tissue-viability policy, risk assessment, prevention, skin monitoring, wound treatment and record keeping.
Verbatim wording from the response “• Training and Supervision sessions took place with all staff at the Home on 22nd October 2025, and 18th December 2025 led by the Regional Operational Trainer and Clinical Development Nurse. As previously advised, the training focussed on pressure area care and management of pressure ulcer/wounds. During the training there were refresher sessions on the Barchester Tissue Viability and Skin Tear Policy and specific focus on early and appropriate management of risk, use of preventative measures, skin monitoring, pressure ulcer treatment and record keeping. The Clinical Development Nurse assigned to the Home uses the SSKIN bundle framework approach to promote comprehensive risk assessment, monitoring and care as a tool in pressure ulcer prevention. Early identification of skin compromise through regular checks is reinforced as part of daily care.” Source location Response from Barchester Healthcare Ltd
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 Train staff on dynamic-air-mattress settings, regular equipment checks and obtaining replacement mattresses outside hours.
Verbatim wording from the response “• Advice has been provided by the Regional Operational Trainer and Clinical Development Nurse in respect of the use of beds and mattresses as vital equipment for the management of skin integrity and as an aid to prevention of damage to skin. Full staff training has been carried out with the Head of Maintenance at the Home in respect of the use of dynamic air mattress settings and how to use these appropriately and the importance of regular checks. Refresher training has also been provided to the Home team in respect of how to access mattress replacements in the event of a mattress failure occurring out of hours.” Source location Response from Barchester Healthcare Ltd
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 Deliver reflective sessions and disseminate inquest learning to Home staff on pressure-injury risk, prevention, treatment and documentation.
Verbatim wording from the response “• Post inquest reflective sessions with staff carried out by Regional Manager with focus on the matters of concern raised by you during the inquest and in your findings and conclusion delivered on 8 December 2025.” Source location Response from Barchester Healthcare Ltd
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 Train staff and maintenance personnel to set, check and replace dynamic air mattresses appropriately, including accessing out-of-hours replacements.
Verbatim wording from the response “• Advice has been provided by the Regional Operational Trainer and Clinical Development Nurse in respect of the use of beds and mattresses as vital equipment for the management of skin integrity and as an aid to prevention of damage to skin. Full staff training has been carried out with the Head of Maintenance at the Home in respect of the use of dynamic air mattress settings and how to use these appropriately and the importance of regular checks. Refresher training has also been provided to the Home team in respect of how to access mattress replacements in the event of a mattress failure occurring out of hours.” Source location Response from Barchester Healthcare
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 Review and update residents’ assessments, risk assessments and care plans monthly through the Resident of the Day process.
Verbatim wording from the response “ii. All residents are part of the Resident of the Day process. As part of Resident of the Day process, all assessments, risk assessments and care plans are reviewed monthly and updated as required if needs change. This is completed by the Nurse leading the shift.” Source location Response from Barchester Healthcare
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 Implement and embed the Enable electronic records and case-management system.
Verbatim wording from the response “• Introduction and embedding of electronic records and case management system ‘Enable’.” Source location Response from Barchester Healthcare
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 Hold bi-weekly clinical governance meetings to review high-risk residents, tissue-viability issues, referrals and clinical deterioration.
Verbatim wording from the response “vi. In accordance with Barchester procedures the Home holds a monthly clinical governance meeting. Following the appointment of a new General Manager at the” Source location Response from Barchester Healthcare
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 Conduct observations, staff supervisions and equipment-use support covering repositioning, moving and handling, mattresses and pressure-relieving equipment.
Verbatim wording from the response “• The Regional Operational Trainer and Clinical Development Nurse have attended the Home on several occasions to carry out observations and monitoring and to identify any further areas for improvement for the clinical team. Visits took place on 7, 10, 15 and 22 October. On 15 October 2025 the Clinical Development Nurse attended the Home to review equipment used by staff to support resident care needs. A group session with staff was held to discuss availability of equipment, appropriate use and processes and procedures to assess need and request equipment including pressure relieving mattresses. During an observation visit on 22 October 2025 there was a focus on Moving and Handling techniques used by staff at the Home. No concerns” Source location Response from Barchester Healthcare
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 Carry out monthly skin-integrity audits and additional Regional Manager reviews of high-risk residents’ interventions, equipment, care plans and Waterlow scores.
Verbatim wording from the response “v. A monthly skin integrity audit is completed by the General Manager which reviews all residents deemed as ‘high’ or ‘very high’ risk of pressure damage. This looks at care interventions and equipment in place, including mattresses and chair cushions. The audit also reviews the care plans and the completion of Waterlow scores in line with the Resident of the Day process. The Regional Manager completes this audit bi-monthly to add increased oversight and safety netting and to identify any further interventions required for residents.” Source location Response from Barchester Healthcare
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 Deliver pressure-area, wound-management, tissue-viability, risk-assessment, prevention, skin-monitoring and record-keeping training with supervision and knowledge checks for staff.
Verbatim wording from the response “• Training and Supervision sessions took place with all staff at the Home on 22nd October 2025, and 18th December 2025 led by the Regional Operational Trainer and Clinical Development Nurse. As previously advised, the training focussed on pressure area care and management of pressure ulcer/wounds. During the training there were refresher sessions on the Barchester Tissue Viability and Skin Tear Policy and specific focus on early and appropriate management of risk, use of preventative measures, skin monitoring, pressure ulcer treatment and record keeping. The Clinical Development Nurse assigned to the Home uses the SSKIN bundle framework approach to promote comprehensive risk assessment, monitoring and care as a tool in pressure ulcer prevention. Early identification of skin compromise through regular checks is reinforced as part of daily care.” Source location Response from Barchester Healthcare
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 Maintain electronic notifications and management oversight of clinical-status changes, wound categorisation, care planning and treatment regimes.
Verbatim wording from the response “(iii) The General Manager at Windmill Manor Care Home has been provided with dedicated support from the Managing and Regional Directors and the Clinical Development Nurse during the recent period of change at the home. When changes to a resident’s clinical status are identified, including deterioration to skin integrity, these are added to the online systems which immediately notifies the Clinical” Source location Response from Barchester Healthcare
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 Carry out daily care-record sampling and monthly documentation audits, with management follow-up of identified actions.
Verbatim wording from the response “iii. The General Manager daily walk around of the Home includes ad hoc sampling of resident care records and supporting documentation. This audit tool also directs the General Manager to approach and question both residents, families and staff to identify any concerns. Any actions identified are discussed at the daily stand-up meeting and then carried forward to the next meeting, to ensure review of completion.” Source location Response from Barchester Healthcare
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 Provide ongoing weekly Clinical Development Nurse reviews of skin-integrity risks, wound assessments, categorisation and care plans.
Verbatim wording from the response “• The Clinical Development Nurse now visits the Home on a weekly basis to review the approach to the management of risk to skin integrity and care and treatment plans in place where skin damage has been identified for any resident. She checks that wound assessment and categorisation is being completed correctly with review of wounds by staff in person supported by photographs. She attends the daily stand-up meeting during her visit to follow up on assessments and referrals and any clinical concerns. She is also available for advice and assistance to all staff outside these visits and can review concerns on an ‘as needed’ basis. She has reported an improvement overall in the approach of staff and their recognition of the importance of early interventions and comprehensive treatment plans.” Source location Response from Barchester Healthcare
Open published response
27 May 2025 Keith Ineson · Prevention of Future Deaths report Blackpool and the Fylde
View report summary
Concerns raised 2 Failure to conduct an appropriate post-fall injury assessment View source Failure to record all post-fall observation scores View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Keith Ineson · 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
Keith Ineson, a resident at Glenroyd Care Home, suffered an unwitnessed fall on 26 April 2024 and was subsequently treated for a fractured hip. Following surgery, he suffered a choking episode, developed aspiration pneumonia and died at Blackpool Victoria Hospital on 6 May 2024. The principal concern was that observation scores taken after the fall were not all recorded, leaving gaps in the information available to assess whether escalation to medical services was needed and creating a risk of further death.
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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an appropriate post-fall injury assessment
Wider context from the report “Following the fall on 26 April 2024, I found that the senior carer who checked Mr Ineson for signs of injury had conducted an inappropriate assessment .
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record all post-fall observation scores
Wider context from the report “It was noted in the evidence, that the observation scores taken for Mr Ineson following his fall had not all been recorded in Mr Ineson’s care notes . This left a gap in the evidence as to reviewing the need for escalation to medical services after the fall.
I received from witnesses who gave evidence before me, helpful assistance concerning several issues about learning and changes that had been made following Mr Ineson’s death.
I could not identify changes to the record keeping system though, and as such found that the issue around the absence of recording observation scores following a fall gave rise to a risk of further death . This was because the record keeping was inaccurate, contained gaps in the information , and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013.
” 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 Deliver moving-and-handling refresher training covering post-fall procedures and techniques to mitigate falls.
Verbatim wording from the response “In addition, the members of staff involved in the incident attended a Moving & Handling refresher training day with an Operational Trainer on 3rd June 2024. The moving and” Source location Response from Barchester Healthcare Ltd
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 Deliver targeted training and supervision on post-fall documentation, escalation, observation recording and lessons learned from the incident.
Verbatim wording from the response “Following the Inquest, Barchester revisited the issue of recording of all resident interactions and observations to ensure this is undertaken clearly, consistently and contemporaneously. We acknowledge that there was a need to improve the accuracy and regularity of record keeping. We have taken appropriate action in relation to training and technology to ensure that all interactions with patients are recorded.” Source location Response from Barchester Healthcare Ltd
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 EnabLE drop-in support, documentation audits and remote monitoring for adherence and learning needs.
Verbatim wording from the response “As part of the continuing programme of learning the region’s EnabLE champion who supports the home with EnabLE will continue with the provision of drop-in sessions, documentation audit and will continue to monitor remotely for any trends in learning needed around the digital system to ensure adherence to the actions triggered in the new system.” Source location Response from Barchester Healthcare Ltd
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 Implement the EnabLE digital care-planning system for scheduled post-fall observations, alerts and point-of-care recording.
Verbatim wording from the response “The Learned Coroner will recall that in addition to the actions undertaken which were set out in the action plan submitted prior to the inquest, ████████, the Registered Manager of Glenroyd Care Home explained that Barchester has implemented a new digital care planning system called EnabLE which provides Barchester healthcare services with the ability to set up planned post fall interaction scheduled observations that can be recorded at the point of care to ensure accuracy and eliminate the risk of absent recordings. The system is relatively new, and we have completed some additional training with staff and themed supervisions, to ensure they know how to add to the scheduled observations. We are auditing the use of the systems – see below.” Source location Response from Barchester Healthcare Ltd
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 Complete NEWS2, RESTORE and sepsis training and themed supervision for recognising deteriorating residents.
Verbatim wording from the response “Our new digital system limits any opportunities missing entries in relation to observations. Our observations are recorded on the digital system in a NEWS2 (National Early Warning Score) observation record, rather than manually written. The training for this has been completed in the home, and we also have oversight by the regional Clinical Development Nurse who supports all her homes monthly and looks at the system to make sure everything is recorded as it should be.” Source location Response from Barchester Healthcare Ltd
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 Provide documentation prompt sheets to support completion of post-fall records.
Verbatim wording from the response “In addition to the training programme and support staff are provided with an added prompt sheet to support them in the completion of documentation. This is part of a “belt and braces” approach to training.” Source location Response from Barchester Healthcare Ltd
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 Review the falls policy with clinical staff and reinforce procedures for responding and escalating after falls.
Verbatim wording from the response “Further, lessons learned as stated above, include correct moving & handling techniques. The falls policy has been reviewed by all clinical staff to ensure that everyone is aware of the policy and procedure following a fall (supported by the NEWS2 and RESTORE training above) therefore any need for escalation to medical services following a patient’s fall will be abundantly clear. The prompt sheets and guides created give an oversight of completion and can be checked by management, thereby mitigating the risk of the recording of inaccurate and irregular observations.” Source location Response from Barchester Healthcare Ltd
Open published response
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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 Complete induction, including NEWS2 training, for three new bank nurses.
Verbatim wording from the response “The training statistics for the home are 100% for NEWS2 in the home which ensures the accuracy, frequency and consistency of recording observations. Every Nurse, Senior carer and Care Practitioner has completed NEWS2 training, and three new bank nurses are in the process of completing their induction of which NEWS2 is part of the process. All NEWS2 training is completed on induction into the home, we have checked the recorded dates of NEWS2 training, and the dates have been recorded in the Learning Management system.” Source location Response from Barchester Healthcare Ltd
Open published response
Concerns raised 3 Failure to label retrospective care records View source Failure to maintain accurate care records View source Delays in calling an emergency ambulance for very unwell residents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Ian George Stanton SIMPSON · 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
Ian Simpson fell in August 2024, sustained a traumatic spinal injury, and later required a long-term catheter. He was found unresponsive at Magnolia Court Care Home on 16 December 2024, was taken to hospital after a delay in calling an ambulance, and died that evening from sepsis secondary to a urine infection. The principal concerns were the delay in calling an ambulance and inadequate and inaccurate care-home record-keeping, including retrospective or misleading entries.
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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to label retrospective care records
Wider context from the report “2. The notes from the care home were considered in great detail during the inquest, particularly the care notes from the morning of 16 December 2024. These raised significant concern about their adequacy and accuracy. While the deficiencies in record-keeping did not cause or contribute to death in the specific circumstances of this case, I am mindful of the importance of clear and accurate record-keeping to the delivery of safe and effective care more widely.
The issues included:
• an entry that was plainly not correct and therefore gave a misleading impression of interactions that staff had with Mr Simpson at or about the time of his being found unresponsive;
• an entry suggesting that Mr Simpson was ‘awake and lying in bed’, when he had already been found unresponsive some time earlier, suggesting that the entry was either retrospective (and not labelled as such) or simply incorrect;
• a series of notes, likely to have been retrospective but not labelled as such , giving a misleading impression of the course of events that morning.
While I was provided with some evidence that action had been taken in relation to this matter (such as an audit of records), I found that the evidence provided insufficient reassurance that the risk was sufficiently reduced.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain accurate care records
Wider context from the report “2. The notes from the care home were considered in great detail during the inquest, particularly the care notes from the morning of 16 December 2024. These raised significant concern about their adequacy and accuracy . While the deficiencies in record-keeping did not cause or contribute to death in the specific circumstances of this case, I am mindful of the importance of clear and accurate record-keeping to the delivery of safe and effective care more widely.
The issues included:
• an entry that was plainly not correct and therefore gave a misleading impression of interactions that staff had with Mr Simpson at or about the time of his being found unresponsive;
• an entry suggesting that Mr Simpson was ‘awake and lying in bed’, when he had already been found unresponsive some time earlier, suggesting that the entry was either retrospective (and not labelled as such) or simply incorrect ;
• a series of notes, likely to have been retrospective but not labelled as such, giving a misleading impression of the course of events that morning .
While I was provided with some evidence that action had been taken in relation to this matter (such as an audit of records), I found that the evidence provided insufficient reassurance that the risk was sufficiently reduced.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in calling an emergency ambulance for very unwell residents
Wider context from the report “1. Mr Simpson was found unresponsive by care home staff at about 09:30 on 16 December 2024, and an emergency ambulance was not called until 10:19 . On the evidence in this particular case, that delay did not more than minimally contribute to death; however, it would or should have been obvious to staff that the resident was very unwell and required an ambulance as soon as possible .
This raises the concern that such a delay, if repeated, places others at serious risk . My concern was compounded by the evidence from the manager (which I did not wholly accept) that it would be reasonable to take this period of time for a nurse to be alerted, assess the resident, and decide whether an ambulance was required.
” Open source report
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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 Introduce EnabLE digital care planning, handheld devices and staff recording requirements to standardise care records and support auditing.
Verbatim wording from the response “Introduction of EnabLE” Source location Response from Barchester Healthcare Ltd
Open published response
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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 remotely reviewing Home documentation quality through the assurance audit programme.
Verbatim wording from the response “We have the ability to review the documentation completed by staff at the Home remotely; the Regional Director and Regional Clinical Development Nurse continue to consider the quality of entries as part of the ongoing assurance audit programme. We are currently working on setting up a trial of an integrated digital accident and incident recording system, this will be linked to the digital care planning system to allow for the capture of key information relating to the incident in real time which will support our investigation of incidents in future.” Source location Response from Barchester Healthcare Ltd
Open published response
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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 Provide staff with Clinical Shots guidance for assessing residents and responding to deterioration.
Verbatim wording from the response “• Staff in the Home have also been provided with Barchester ‘Clinical Shots’ guidance, to inform their assessment of residents and the steps to be taken in response.” Source location Response from Barchester Healthcare Ltd
Open published response
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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 Complete themed supervisions covering RESTORE2 clinical judgement and managing resident deterioration.
Verbatim wording from the response “• Themed supervisions have been completed with the support of Divisional Clinical Lead Nurse, the Clinical Development Nurse and both the Regional Director and General Manager of the Home. These themed supervisions cover two main areas:” Source location Response from Barchester Healthcare Ltd
Open published response
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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 Provide refresher training on EnabLE functionality, record-keeping expectations, policy and accurate contemporaneous recording.
Verbatim wording from the response “Following the Inquest, we have provided refresher training at the Home in relation to the functionality of the system, the organisation’s expectations and policy in relation to record keeping and the importance of accurate and contemporaneous recording.” Source location Response from Barchester Healthcare Ltd
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 Provide EnabLE implementation training and coaching to staff before, during and after system introduction.
Verbatim wording from the response “EnabLE was introduced in December 2024. Our objectives were to standardise recording, increase visibility of day-to-day care interactions at management level, improve our ability to audit and conduct trend analysis of incidents and staff performance. We are confident the introduction of this digital care support planning system will allow the organisation to continually improve the standard of record keeping and delivery of prompt and effective care. Now our care staff, as distinct from nursing staff, have handheld devices and are expected to record narratives at the point of care which represents a completely new way of working for them having previously completed minimal resident records on paper.” Source location Response from Barchester Healthcare Ltd
Open published response
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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 Present learning from the matter to home managers, including escalation expectations and immediate 999 calls for newly unresponsive residents.
Verbatim wording from the response “• I presented learning from this matter to all our home managers during our ‘Leading the way’ internal communication webinar on 19th May 2025. This session covered responsibility to escalate any concerns in relation to residents’ health and welfare and utilise the guidance provided in our Deteriorating Resident’s Policy and that 999 must be immediately called for an unresponsive resident where this represents a new presentation.” Source location Response from Barchester Healthcare Ltd
Open published response
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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 Staff did not consider a 49-minute escalation period appropriate for an unresponsive resident and recalled no significant delay in this case.
Verbatim wording from the response “• Despite the evidence given, no other member of the Nursing team considered that 49 minutes is an appropriate length of time to escalate concerns to 999 if a resident is found unresponsive and staff did not recall there being any significant delay in doing so in Mr Simpson’s case.” Source location Response from Barchester Healthcare Ltd
Open published response
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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 reported 09:30 incident time is unsupported; staff identified no concerns about the resident’s health or wellbeing then.
Verbatim wording from the response “• it is not clear where the time of 09:30am as the time of the incident originates. Whilst this is recorded in the Accident and Incident Form, no member of staff suggested that there were any concerns at this time in respect of Mr Simpson’s health and wellbeing.” Source location Response from Barchester Healthcare Ltd
Open published response
9 Feb 2023 Bridget GORMLEY · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 3 Lack of staff understanding of duties and responsibilities to update residents’ documentation View source Failure to consider measures to mitigate residents’ increased falls risk View source Failure to update residents’ falls risk assessment and care plan documentation following falls View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Bridget GORMLEY · 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
Bridget Gormley fell at her care home in Worcester on 20 July 2022 and was found to have significant traumatic intracranial bleeding. She was transferred to Worcestershire Royal Hospital, where she died on 31 July 2022. The principal concerns were that her falls risk assessment and care plan were not updated after repeated falls, and that staff may not have understood their duties to update residents’ documentation.
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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding of duties and responsibilities to update residents’ documentation
Wider context from the report “(1) During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court’s registered home manager, ████████, conceded in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care plan document were updated following any of these falls, and that they should have been so updated. This meant that:
(a) Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that she presented an increased risk of suffering a fall; and
(b) Measures to mitigate that increased risk were not considered. Such measures could have included:
(i) Asking a GP to refer Mrs. Gormley to the falls clinic;
(ii) Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising;
(iii) Referring her to Occupational Therapy for mobility aids such as a walking stick or frame;
(iv) Briefing staff at Latimer Court to intervene whenever Mrs. Gormley was seen mobilising by herself, and to offer her assistance.
(2) ████████ was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents’ documentation in such circumstances.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to consider measures to mitigate residents’ increased falls risk
Wider context from the report “(1) During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court’s registered home manager, ████████, conceded in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care plan document were updated following any of these falls, and that they should have been so updated. This meant that:
(a) Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that she presented an increased risk of suffering a fall; and
(b) Measures to mitigate that increased risk were not considered. Such measures could have included:
(i) Asking a GP to refer Mrs. Gormley to the falls clinic;
(ii) Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising;
(iii) Referring her to Occupational Therapy for mobility aids such as a walking stick or frame;
(iv) Briefing staff at Latimer Court to intervene whenever Mrs. Gormley was seen mobilising by herself, and to offer her assistance.
(2) ████████ was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents’ documentation in such circumstances.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to update residents’ falls risk assessment and care plan documentation following falls
Wider context from the report “(1) During the course of her evidence, the inquest heard that Mrs. Gormley had suffered four falls at Latimer Court between 31 March 2022 and 4 April 2022, and a further four falls between 12 July 2022 and 17 July 2022. Latimer Court’s registered home manager, ████████, conceded in her evidence that neither Mrs. Gormley’s Falls Risk Assessment document, nor her Falls Care plan document were updated following any of these falls , and that they should have been so updated. This meant that:
(a) Staff at Latimer Court who were looking after Mrs. Gormley may not have been aware that she presented an increased risk of suffering a fall; and
(b) Measures to mitigate that increased risk were not considered. Such measures could have included:
(i) Asking a GP to refer Mrs. Gormley to the falls clinic;
(ii) Placing a sensor mat by her bed or chair, to alert staff to when she was mobilising;
(iii) Referring her to Occupational Therapy for mobility aids such as a walking stick or frame;
(iv) Briefing staff at Latimer Court to intervene whenever Mrs. Gormley was seen mobilising by herself, and to offer her assistance.
(2) ████████ was unable to explain why these important documents had not been updated as they should have been by staff at Latimer Court. There is therefore concern that staff at Latimer Court did not, and may still not understand their duties and responsibilities to update residents’ documentation in such circumstances.
” Open source report
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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 Amend monthly clinical governance meetings to review each resident’s falls and falls history.
Verbatim wording from the response “entered onto the clinical governance system within 24 hours. To address this, we have amended our monthly clinical governance meeting requirements to include a review of falls for any one individual and their falls history. These meetings are minuted and require discussion of residents having a fall or found on the floor in line with Barchester’s Falls Management Policy to ensure that all measures are in place to mitigate the risk of further falls and that the relevant Healthcare Professionals and equipment is accessed and utilised. We have also introduced a regional falls champion forum, chaired by our Divisional clinical lead nurses. This will have an emphasis on prevention but also include reviews of individuals who have fallen, and the documentation required to support them and plan for their needs.” Source location Response from Barchester Healthcare
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 Introduce a regional falls champion forum chaired by divisional clinical lead nurses.
Verbatim wording from the response “entered onto the clinical governance system within 24 hours. To address this, we have amended our monthly clinical governance meeting requirements to include a review of falls for any one individual and their falls history. These meetings are minuted and require discussion of residents having a fall or found on the floor in line with Barchester’s Falls Management Policy to ensure that all measures are in place to mitigate the risk of further falls and that the relevant Healthcare Professionals and equipment is accessed and utilised. We have also introduced a regional falls champion forum, chaired by our Divisional clinical lead nurses. This will have an emphasis on prevention but also include reviews of individuals who have fallen, and the documentation required to support them and plan for their needs.” Source location Response from Barchester Healthcare
Open published response
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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 Develop Latimer Court checklists or prompts with the Clinical Development Nurse in line with the Falls Management Policy.
Verbatim wording from the response “Any checklists or prompts to be used at Latimer Court by the home team will be developed in liaison with the Clinical Development Nurse and will follow the requirements of the Falls Management Policy as to actions to be taken. As part of the training staff will be required to review the environment in which the residents live, practice writing risk assessments and consider how residents needs and risks may change and to develop professional curiosity about residents’ presentation and any referrals and actions that should flow from a falls incident.” Source location Response from Barchester Healthcare
Open published response
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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 Update the organisational Falls Management Policy and share the update with Latimer Court’s senior care team.
Verbatim wording from the response “(e) Barchester’s Director of Nursing has undertaken a review of policies, processes and procedures in relation to falls and falls management. The Barchester Healthcare policy for Falls Management has been subsequently updated and this update has been shared by the General Manager of Latimer Court with the home team, specifically the senior care team whose responsibility it is to manage falls.” Source location Response from Barchester Healthcare
Open published response
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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 Deliver refresher training at Latimer Court on completing documentation, including risk-related detail and timely updates.
Verbatim wording from the response “(j) As part of the lessons learnt as identified by the General Manager at Latimer Court it was highlighted that staff required further training from the organisation’s Clinical Development Nurse in the approach to and completion of documentation. Specifically, when to complete documentation and the requisite detail to be included in the entries into documentation. Following completion of the inquest and receipt of the Regulation 28 Report, the Managing and Regional Directors have made arrangements for further refresher training to be delivered at Latimer Court with follow up by the Regional Manager and Quality” Source location Response from Barchester Healthcare
Open published response
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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 Deliver refresher training at Latimer Court on the Falls Management Policy and post-fall risk-review procedures.
Verbatim wording from the response “(k) As part of lessons learnt it is recognised by the General Manager at Latimer Court that staff require further training on the Barchester Falls Management Policy. If staff had followed the policy in this case, they would have followed the prompts to ensure that every aspect of the risk review was undertaken along with the immediate action following a fall or found on the floor incident. This includes consideration of the environmental orientation tool which should be completed preadmission and on admission and revisited following a fall. The Managing and Regional Directors have therefore made arrangements for further refresher training to be delivered at Latimer Court with follow up by the Regional Director and Quality Assurance Team. This will take place with the documentation training over the next 6 weeks and will be repeated as necessary.” Source location Response from Barchester Healthcare
Open published response
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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 Develop and introduce a Post Falls Assessment Tool covering injury assessment, observations and escalation.
Verbatim wording from the response “(f) Barchester Healthcare have also now developed and introduced a specific Post Falls Assessment Tool to aid with the assessment of a resident following a fall or found on floor incident. This assessment process explores pain, any bruising or wounds and any changes in limb movement or walking. It also makes clear the process and frequency of observations and escalation should there be a change from a resident’s baseline.” Source location Response from Barchester Healthcare
Open published response
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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 identified practice matters were unlikely to have affected the resident’s outcome.
Verbatim wording from the response “Following this very sad incident we have made a number of changes to the provision of care and services at Latimer Court, and these have been adopted across the organisation in other services and divisions where appropriate. For the purpose of this response, we have considered the concerns raised by you and where possible we have grouped together details of assurance measures where these appear to deal with more than one area of concern. Whilst it is unlikely that the matters referred to below would have affected the outcome for Mrs Gormley, there are matters of practice identified where the need for improvement has been recognised and dealt with.” Source location Response from Barchester Healthcare
Open published response
17 Dec 2019 Iris Irene SKINNER · Prevention of Future Deaths report Surrey
View report summary
Concerns raised 1 Failure to ensure agency staff are familiar with the Head Injury Policy View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Iris Irene SKINNER · 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
Iris Irene Skinner, a resident at Windmill Manor Care Home, fell on 18 October 2018 and died in hospital on 23 October 2018 after sustaining a fatal head injury. The inquest identified insufficient neurological observations, incomplete recording of observations, and a delay in calling an ambulance after she became unresponsive. A principal concern was that agency staff at the care home, and potentially elsewhere in the Barchester Healthcare group, may not have been familiar with the Head Injury Policy.
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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure agency staff are familiar with the Head Injury Policy
Wider context from the report “The court heard evidence from Jayne Holloway, a Regional Director for Barchester Healthcare who informed the court that since Mrs Skinner’s death all trained permanent staff at the home have been asked to confirm that they have read and are familiar with the Head Injury policy.
However, the court also heard evidence that a significant number of agency staff are employed by the home and that the same process has not been followed in respect of agency staff .
- Agency staff employed by Windmill Manor Care Home in Oxted, and potentially more broadly across the Barchester Healthcare group, may be unfamiliar with the Barchester Healthcare Head Injury Policy .
” Open source report
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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 Disseminate the revised agency nurse induction procedure through staff notices and individual briefings.
Verbatim wording from the response “• Notices have been put on each community staff notice board in relation to the new procedure for agency nurse induction and the General Manager has planned to speak to each individual nurse regarding the changes by 17th January 2020. I attach evidence that two Barchester Nurses have already been updated. (pdf: Staff signatures)” Source location 2019-0427-Response-from-Barchester-Healthcare-Ltd-Redacted
Open published response
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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 Print and introduce a modified agency worker induction checklist across all Barchester homes, incorporating the pocket guide once available.
Verbatim wording from the response “• The timeframe for completing the printing and introduction across all the Barchester homes for the modified induction checklist, pocket guide and poster is the end of February 2020. We would be pleased to send a copy of the pocket guide to you once the pocket guide has been produced.” Source location 2019-0427-Response-from-Barchester-Healthcare-Ltd-Redacted
Open published response
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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 Provide an agency folder containing key policies and require agency nurses to review and sign acknowledgment during induction.
Verbatim wording from the response “At Windmill Manor the specific actions that have been taken include:” Source location 2019-0427-Response-from-Barchester-Healthcare-Ltd-Redacted
Open published response
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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 Monitor compliance with the revised agency induction checklist through Regional Director checks and the Barchester audit programme.
Verbatim wording from the response “• To monitor compliance against the new agency induction checklist which will include distribution of the pocket guides and signatures on” Source location 2019-0427-Response-from-Barchester-Healthcare-Ltd-Redacted
Open published response
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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 Develop a pocket guide summarising key points from ten policies, including head injury and falls policies, with FAQs and advice contacts for agency staff.
Verbatim wording from the response “• As part of our Quality Governance Framework Barchester Healthcare has a ‘Policy on policies’ which identifies the process, formulation and format of all our organisational policies. At the beginning of each policy there are ‘Key policy points listed’ which summarise and identify for quick reference the key messages and practices in each of the policies.” Source location 2019-0427-Response-from-Barchester-Healthcare-Ltd-Redacted
Open published response
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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 Complete spot checks of agency nurses’ knowledge to test understanding of the relevant policies.
Verbatim wording from the response “• The General Manager at Windmill Manor has also agreed to complete spot checks with agency nurses on duty to test their knowledge to ensure they have read and understood the policies.” Source location 2019-0427-Response-from-Barchester-Healthcare-Ltd-Redacted
Open published response
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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 Introduce a wall-mounted poster providing key policy information for staff in each home.
Verbatim wording from the response “• To supplement the pocket guide, in the home staff room there will be a wall mounted commercially produced poster which contains very similar information as the pocket guide and will provide a reference point for all staff in the home in relation to key policy information.” Source location 2019-0427-Response-from-Barchester-Healthcare-Ltd-Redacted
Open published response
19 Oct 2017 Ronald Maurice Brewer · Prevention of Future Deaths report Gloucestershire
View report summary
Concerns raised 3 Deficiencies in the dispensation of palliative medications View source Deficiencies in the administration of medications View source Failure to document palliative medications View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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. 9
Action
Appoint a palliative-care Deputy Manager to support end-of-life training and practice, supervise implementation, and develop local palliative-care team involvement.
Stated completedThe respondent said that this action was complete when they made their response on 28 November 2017. View source
Action
Provide clinical supervision on the home’s medication-transcription policy following the identified transcription error.
Stated completedThe respondent said that this action was complete when they made their response on 28 November 2017. View source
Action
Assess staff competencies and practices in medicine management and record keeping.
Stated completedThe respondent said that this action was complete when they made their response on 28 November 2017. View source
Action
Update central medicine-management and end-of-life policies to reflect good practice.
Stated completedThe respondent said that this action was complete when they made their response on 28 November 2017. View source
Action
Revisit end-of-life and medication policies with staff and reinforce multidisciplinary working.
Stated completedThe respondent said that this action was complete when they made their response on 28 November 2017. View source
Action
Use the Zomorph recording error as a learning point in staff supervision, training, and assessment.
Stated completedThe respondent said that this action was complete when they made their response on 28 November 2017. View source
Action
Update end-of-life and medication policies with guidance on individualised dosing decisions for prescribed dosage ranges, including analgesia and controlled medicines.
Stated completedThe respondent said that this action was complete when they made their response on 28 November 2017. View source
Action
Deliver three months of training covering end-of-life planning, anticipatory care, communication, medication decision-making, and medication management.
Stated plannedThe respondent said that this action was planned when they made their response on 28 November 2017. View source
Action
Provide further staff training on medicine management and record keeping.
Stated completedThe respondent said that this action was complete when they made their response on 28 November 2017. View source See 6 more actions
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AI-generated summary
Ronald Maurice Brewer · 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
Ronald Maurice Brewer was an 87-year-old man with significant medical conditions who was admitted to hospital, discharged to a care home for end-of-life care, and died shortly after receiving prescribed palliative and anticipatory medication. The substantive concern related to the administration, documentation, and dispensing of palliative medications.
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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in the dispensation of palliative medications
Wider context from the report “1. The administration of medications, including in particular the documentation of and dispensation of palliative medications .
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Deficiencies in the administration of medications
Wider context from the report “1. The administration of medications , including in particular the documentation of and dispensation of palliative medications.
” 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 Barchester Healthcare Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document palliative medications
Wider context from the report “1. The administration of medications, including in particular the documentation of and dispensation of palliative medications.
” Open source report
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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 Appoint a palliative-care Deputy Manager to support end-of-life training and practice, supervise implementation, and develop local palliative-care team involvement.
Verbatim wording from the response “a. A Deputy Manager has been appointed at Badgeworth Court with a background in palliative care and she has been given the responsibility to support training and practice in end of life care in the home. Also to continue” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 Provide clinical supervision on the home’s medication-transcription policy following the identified transcription error.
Verbatim wording from the response “h. We considered a recording error made when Mr Brewer’s discharge notes were transcribed on admission. Two staff members failed to correctly transcribe Rivaroxaban from the hospital chart to the care home MAR chart. Following investigation the staff members conceded that, during transcription they had failed to consult the discharge summary and had solely referred to the hospital MAR. Clinical supervision was given to the two staff members on the relevant home policy regarding transcription. Both staff members no longer work in the home.” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 Assess staff competencies and practices in medicine management and record keeping.
Verbatim wording from the response “b. The staff at Badgeworth Court have undertaken an assessment of their competencies and practices in relation to management of medicines and they have attended further training on this topic and in relation to record keeping.” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 Update central medicine-management and end-of-life policies to reflect good practice.
Verbatim wording from the response “j. Policies and procedures have been updated centrally to reflect good practice in medicine management and End of life care.” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 Revisit end-of-life and medication policies with staff and reinforce multidisciplinary working.
Verbatim wording from the response “e. The end of life and management of medication policies have been re-visited with staff and we have reiterated the importance of multi-professional working in end of life care.” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 Use the Zomorph recording error as a learning point in staff supervision, training, and assessment.
Verbatim wording from the response “i. Whilst investigating the drug administration notes and checking remaining stocks of Zomorph it was noted that a recording error had taken place during the first administration of the drug at Badgeworth Court. The dose had been recorded on the hospital MAR chart instead of the newly created home MAR chart. The error created two distinct risks;” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 Update end-of-life and medication policies with guidance on individualised dosing decisions for prescribed dosage ranges, including analgesia and controlled medicines.
Verbatim wording from the response “g. In our review it was noted that during Mr Brewer’s end of life care, a decision was made to administer Midazolam at a dose at the highest end of the prescribed dose range. Our finding was that the decision was appropriate and was made by an experienced nurse having considering the individual factors specific to Mr Brewer including his height, weight and level of agitation. Nevertheless, it was identified that more could be done to support” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 Deliver three months of training covering end-of-life planning, anticipatory care, communication, medication decision-making, and medication management.
Verbatim wording from the response “d. The General Manager at Badgeworth has arranged for ongoing training over the next 3 months, the training is to cover;” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 Provide further staff training on medicine management and record keeping.
Verbatim wording from the response “b. The staff at Badgeworth Court have undertaken an assessment of their competencies and practices in relation to management of medicines and they have attended further training on this topic and in relation to record keeping.” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
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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 highest-end prescribed Midazolam dose was considered appropriate, based on the resident’s individual factors and agitation.
Verbatim wording from the response “g. In our review it was noted that during Mr Brewer’s end of life care, a decision was made to administer Midazolam at a dose at the highest end of the prescribed dose range. Our finding was that the decision was appropriate and was made by an experienced nurse having considering the individual factors specific to Mr Brewer including his height, weight and level of agitation. Nevertheless, it was identified that more could be done to support” Source location 2017-0306-Response-by-Barchester-Healthcare-Ltd
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations