Beech Cliffe Grange

Private and voluntary organisations · Residential care home

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First report 14 Nov 2017•Latest report 14 Nov 2017

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Concerns and recipient responses

Statements from Beech Cliffe Grange linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. South Yorkshire (Eastern)

    AI-generated summary

    Steven Jones · 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

    Steven Jones, aged 27, was a non-verbal resident of a care home who became ill with sickness, diarrhoea, loss of appetite and sleep disturbance before dying on 10 December 2013. He was diagnosed with a perforated colon, leading to multi-organ failure and hypoxic brain injury. Concerns included failures to escalate carers’ concerns, insufficient incident reporting, delayed medical referral, and delays in calling emergency services and transferring him to hospital.

    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 Beech Cliffe Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of staff to act directly on residents' illness

    Wider context from the report

    “(3) In practice staff did not act directly in dealing with illness of a resident, rather channelling medical issues through the registered managers. ”
    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 Beech Cliffe Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise illness as requiring incident reporting

    Wider context from the report

    “(2) Staff did not appreciate the importance of incident reports and that such reports encompassed illness. ”
    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 Beech Cliffe Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure the resident and one-to-one carer attend general-practitioner consultations

    Wider context from the report

    “(5) In the case of a non-verbal resident with serious problems very early referral to a general practitioner was not made and when made the resident was not present at the consultation nor was his one to one carer in attendance. ”
    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 Beech Cliffe Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to escalate carers' concerns to senior staff

    Wider context from the report

    “(1) Although a system of written recording was in place, concerns of carers were not emphasised nor escalated to seniors either through incident reports or verbally so that opportunities to initiate full investigations by seniors and/or managers were lost. ”
    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 Beech Cliffe Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in early general-practitioner referral for residents with serious problems

    Wider context from the report

    “(5) In the case of a non-verbal resident with serious problems very early referral to a general practitioner was not made and when made the resident was not present at the consultation nor was his one to one carer in attendance. ”
    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 Beech Cliffe Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of staff to call emergency services for serious incidents

    Wider context from the report

    “(4) On the occasion of a serious incident of faecal vomit, staff did not assume responsibility for calling emergency services but telephoned the registered managers who in turn did not appreciate the seriousness of the situation resulting in a delay in transferring the resident to hospital. ”
    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 Beech Cliffe Grange; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to recognise the seriousness of situations requiring urgent hospital transfer

    Wider context from the report

    “(4) On the occasion of a serious incident of faecal vomit, staff did not assume responsibility for calling emergency services but telephoned the registered managers who in turn did not appreciate the seriousness of the situation resulting in a delay in transferring the resident to hospital. ”
    Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026