Recipient

Beech Dene Residential Care Home

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First report 30 Sep 2020•Latest report 30 Sep 2020

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

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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 Dene Residential Care Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Stoke-on-Trent and North Staffordshire

    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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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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