Concerns raised 9 Failure of district nurses to involve Tissue Viability Nurses View source Failure to record district nurse visits View source Failure to provide pain relief View source Insufficient GP involvement View source Failure of the band 4 nurse to escalate the seriousness of the situation View source Lack of wound treatment assessment charts View source Failure to keep the pressure mattress switched on View source Failure of nursing notes to clearly record positioning and changes to ulcers View source Failure to check pressure areas View source See 6 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Mavis May Lawrence · 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
Mavis May Lawrence, who had severe dementia and required full nursing care, was admitted to hospital with dehydration, deep ungradable pressure sores and a buttock abscess, and later died on 28 February 2019. The inquest concluded that she died from natural causes exacerbated by infected pressure sores. Concerns included gaps in pressure-area checks and care documentation, a pressure mattress being turned off, lack of escalation and pain-relief evidence, insufficient GP involvement, and district nurses not involving tissue viability nurses.
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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of district nurses to involve Tissue Viability Nurses
Wider context from the report “(8) District nurses had not involved Tissue Viability Nurses .
” 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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to record district nurse visits
Wider context from the report “(5)No record of last visit by district nurses on the 27.1.19
” 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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide pain relief
Wider context from the report “(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved. .
” 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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Insufficient GP involvement
Wider context from the report “(7) There was no evidence that the deceased had been provided with any pain relief and the GP had not been sufficiently involved . .
” 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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of the band 4 nurse to escalate the seriousness of the situation
Wider context from the report “(6)There was no evidence that band 4 nurse escalated the seriousness of the situation .
” 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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Lack of wound treatment assessment charts
Wider context from the report “(2)No wound treatment assessment charts after the 18.12.18 to document deterioration of pressure areas.
” 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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to keep the pressure mattress switched on
Wider context from the report “(4)The pressure mattress had been turned off on the 22.1.19
” 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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure of nursing notes to clearly record positioning and changes to ulcers
Wider context from the report “(3)Nursing notes in December 2018 did not portray a clear story of positioning and changes to the ulcers .
” 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 Dene Residential Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to check pressure areas
Wider context from the report “(1)Nursing notes evidence that pressure areas (sacrum/ buttock/hips) were not checked between 3.12.18 and 11.12.18. Wounds to the sacrum and left hip were documented on the 16.12.18 in nursing notes.
” 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