Concerns raised 7 Failure of staff to act directly on residents' illness View source Failure to recognise illness as requiring incident reporting View source Failure to ensure the resident and one-to-one carer attend general-practitioner consultations View source Failure to escalate carers' concerns to senior staff View source Delays in early general-practitioner referral for residents with serious problems View source Failure of staff to call emergency services for serious incidents View source Failure to recognise the seriousness of situations requiring urgent hospital transfer View source See 4 more concerns
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. 2
Action
Use the Anticipatory HealthCare Calendar to assess health symptoms, direct staff responses, record significant communications, train staff, and audit use weekly.
View source
Action
Use the Disability Distress Assessment Tool in daily reporting to identify changes from baseline and prompt behaviour monitoring and health-related reporting.
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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 Limited; 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 Limited; 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 Limited; 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 Limited; 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 Limited; 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 Limited; 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 Limited; 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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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 Anticipatory HealthCare Calendar to assess health symptoms, direct staff responses, record significant communications, train staff, and audit use weekly.
Verbatim wording from the response “In June 2014 the Anticipatory HealthCare Calendar (AHCC) was introduced. ████████ raised the introduction of this system in her evidence to the Inquest on 9 November 2017. This is a NHS proforma that acts as a criteria-referenced monitoring system for health-related issues in those with learning disabilities. Specific symptoms are listed and given a risk level of Green, Amber or Red; amber and red directly link to required specific staff actions and responses, which are described within the tool and recorded on a Significant Communication Sheet, part of the tool. These range from continued monitoring, through administering pain relief or attending a GP surgery when possible, to contacting emergency services immediately. AHCC is a career-level tool that is directive in terms of response to specific symptoms.” Source location 2017-0357-Response-by-Beech-Cliffe-Limited
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 Disability Distress Assessment Tool in daily reporting to identify changes from baseline and prompt behaviour monitoring and health-related reporting.
Verbatim wording from the response “In 2016 we piloted a new daily reporting system which incorporates another NHS system, the Disability Distress Assessment Tool (DisDAT). This is another criteria-referenced behaviour monitoring tool and again links to pain identification and prompts staff to complete behaviour monitoring forms on every occasion when a baseline of “no concerning behaviours seen” is changed. The system is designed as an aide memoire, prompting staff to ensure that any reporting relating to health or other issues has been carried out. We rolled DisDAT out fully at the staff meeting on 17 November 2017. Neither the Coroner nor the Interested Parties explored these issues with Paul and/or Sarah at the Inquest so it was not apparent it was in the scope.” Source location 2017-0357-Response-by-Beech-Cliffe-Limited
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 There was no evidence that staff misunderstood the requirement for incident reports to include illness-related concerns.
Verbatim wording from the response “No evidence was heard that staff did not think incident reports were to include illness. Paul gave evidence to the Inquest on 8 November 2017 that all staff were trained in the completion of incident report forms, which included for illness and when behaviour went from green to amber or to red on the traffic light system. Paul told the Inquest that staff had all completed these forms before, it is not clear why they did not do so in this period for Steven. ████████ told the Inquest on 9 November 2017 that staff had been trained on the completion of incident report forms and had completed them on previous occasions for different behaviours.” Source location 2017-0357-Response-by-Beech-Cliffe-Limited
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 referral timing was considered reasonable because diarrhoea was then the most likely cause and the stool sample was delivered promptly.
Verbatim wording from the response “In evidence to the Inquest on 9 November Sarah confirmed that Monday 25 November 2013 was the first time she was aware of Steven's symptoms, staff had not raised concerns before nor completed any incident report forms. ███████ reviewed the records and noted that before a bout of diarrhoea that morning Steven had not opened his bowels for 3 days, so thought he possibly had diarrhoea and/or a tummy bug. Sarah therefore asked staff to obtain a stool sample for testing.” Source location 2017-0357-Response-by-Beech-Cliffe-Limited
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 resident’s absence from the GP consultation was treated as a justified one-off decision based on infection and behavioural concerns.
Verbatim wording from the response “As set out at paragraph 17 of her witness statement dated 4 October 2017, paragraph 20 of her witness statement dated 4 April 2016 and in evidence to the Inquest on 9 November 2017 Sarah did not take Steven to the appointment on 28 November 2013 because she was concerned that due to his diarrhoea and the unknown result of the stool sample he could be infectious. Also Steven had previously exhibited anxious and challenging behaviour at appointments. She explained her reasoning to the GP, ███████ who was happy to proceed with the appointment. When asked by the Coroner on 8 November 2016 ███████ confirmed that he could have insisted on seeing Steven either at the GP surgery or at the Home.” Source location 2017-0357-Response-by-Beech-Cliffe-Limited
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 were trained and authorised to contact doctors or emergency services directly, rather than being required to route medical issues through managers.
Verbatim wording from the response “All staff had full first aid training, which includes advising them to call an ambulance in an emergency. Sarah gave evidence to the Inquest on 9 November 2017 that all staff have responsibility to meet the needs of residents and all have authority to contact Doctors etc and all telephone numbers are and were kept in a directory in the staff office; there was no need to go up the ladder for approval before the call could be made.” Source location 2017-0357-Response-by-Beech-Cliffe-Limited
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 evidence did not establish that staff encountered or recognised a faecal-vomit emergency requiring an immediate ambulance call.
Verbatim wording from the response “On 7 November 2017 the Inquest heard evidence from ████████ (N'e Hayward) that she was the Senior on duty ███████ told the Inquest that on the morning of 8 December 2013 Clare Gray reported to her that Steven had vomited faeces. Kelly explained to the Inquest that she made sure that Steven was ok and contacted ███████ to relay what had happened. ███████ gave evidence that she could not say for sure if Steven had vomited faeces or if he had passed a bowel motion and then eaten it; the latter had happened previously. The Coroner did not explore this further.” Source location 2017-0357-Response-by-Beech-Cliffe-Limited
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