Recipient

Boldmere Court Care Home

First report 8 May 2017•Latest report 8 May 2017

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing 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 Boldmere Court Care Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

8 May2017
Birmingham and Solihull
Concerns raised6
1. Failure to pass on an accurate history of events
2. Failure of staff to communicate with each other during emergency response
3. Lack of staff first aid training and choking-sign recognition
1. Failure of staff to communicate effectively with challenging behavioural unit patients
2. Poor quality of staff statements after incidents
3. Failure to keep acute and contemporaneous event notes with timings
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

David Sheppard · 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

David Sheppard choked on a doughnut at Boldmere Court on 31 July 2016 and suffered a cardiac arrest and severe hypoxic brain injury. He was taken to Good Hope Hospital, where treatment was withdrawn, and he died on 3 August 2016. The principal concerns were inadequate emergency response, poor communication, failures in record keeping, insufficient first-aid training, and inadequate post-event investigation.

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 Boldmere Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to pass on an accurate history of events
Wider context from the report
“b. Staff failed to pass on an accurate history of what had happened to the deceased resulting in there being a poor understanding of his initial complaint – namely that the deceased was pointing to his throat and was unable to communicate. These factors would indicate choking. ”
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 Boldmere Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to communicate with each other during emergency response
Wider context from the report
“a. The initial nurse who attended the deceased after the emergency call had poor English and needed to give evidence at the inquest through an interpreter. The carer who started CPR had very poor English and also gave evidence through an interpreter. The evidence heard at the inquest was that the response to this emergency was chaotic. Inability of staff to communicate with each other contributed to the chaos and poor decision making. ”
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 Boldmere Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff first aid training and choking-sign recognition
Wider context from the report
“3. Training. Several of the staff who gave evidence had not received first aid training. They did not understand the signs of choking displayed by the deceased. ”
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 Boldmere Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of staff to communicate effectively with challenging behavioural unit patients
Wider context from the report
“c. The patients on the challenging behavioural unit are extremely vulnerable and many suffer from dementia and other conditions. Staff being unable to communicate effectively with these patients may cause harm and confusion. ”
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 Boldmere Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Poor quality of staff statements after incidents
Wider context from the report
“4. Post event investigation. The quality of statements produced by staff immediately after the event was extremely poor. Subsequently staff had a very poor recollection of what happened which seriously hampered the inquest. Direction needs to be given to ensure that accurate and contemporaneous statements are taken after such an incident to ensure events are accurately recorded to enable the correct lessons to be learnt. ”
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 Boldmere Court Care Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to keep acute and contemporaneous event notes with timings
Wider context from the report
“2. Record keeping. Staff failed to keep an acute and contemporaneous note of the events that occurred with timings. This made reconstruction of the event extremely difficult. ”
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 raised6

Failure to pass on an accurate history of events

Failure of staff to communicate with each other during emergency response

Lack of staff first aid training and choking-sign recognition

Failure of staff to communicate effectively with challenging behavioural unit patients

Poor quality of staff statements after incidents

Failure to keep acute and contemporaneous event notes with timings