Recipient

Beech Cliffe Grange

First report 14 Nov 2017•Latest report 14 Nov 2017

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found

0stated actions described

Topic comparisons are not available in the current evidence snapshot.

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.

14 Nov2017
South Yorkshire (Eastern)
Concerns raised7
1. Failure of staff to act directly on residents' illness
2. Failure to recognise illness as requiring incident reporting
3. Failure to ensure the resident and one-to-one carer attend general-practitioner consultations
1. Failure to escalate carers' concerns to senior staff
2. Delays in early general-practitioner referral for residents with serious problems
3. Failure of staff to call emergency services for serious incidents
4. Failure to recognise the seriousness of situations requiring urgent hospital transfer
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
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

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026

Reports, concerns and published responses

Reports over time

Concerns raised7

Failure of staff to act directly on residents' illness

Failure to recognise illness as requiring incident reporting

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

Failure to escalate carers' concerns to senior staff

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

Failure of staff to call emergency services for serious incidents

Failure to recognise the seriousness of situations requiring urgent hospital transfer