Recipient

Bowden Derra Park Limited

First report 13 Mar 2023•Latest report 13 Mar 2023

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 100%
Concerns addressed: 3
Stated actions: 3

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.

100%published responses found

3stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Bowden Derra Park Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

13 Mar2023
Cornwall and Isles of Scilly
Concerns raised3
1. Lack of training or other preparedness for new residents with unusual presentations
2. Delays in reviewing new residents’ Care Plans
3. Failure to continuously monitor residents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 3
1. Action
  Update the Care Plan Policy to define the expected timeframe for reviewing new residents’ care plans after admission.
  Stated completed
2. Action
  Update the nocturnal CCTV monitoring chart to record monitoring periods and explain any gaps.
  Stated completed
3. Action
  Update the Training Policy to specify training and other steps for new residents with unusual presentations.
  Stated completed
AI-generated summary

Lugh Baker · 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

Lugh Baker, a 24-year-old man with Angelman’s syndrome, epilepsy and difficulty swallowing, was found unresponsive at Rosewood House on 21 April 2021 after receiving medication in a chocolate milkshake. CPR was unsuccessful, and the cause of death was recorded as unascertained with an Open Conclusion. Concerns included gaps in monitoring, delays in reviewing new residents’ care plans, and insufficient arrangements for staff unfamiliar with a resident’s unusual presentation.

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 Bowden Derra Park Limited; that does not assign responsibility.
PFD Monitor interpretation
Lack of training or other preparedness for new residents with unusual presentations
Wider context from the report
“iii) Concern was also raised about what steps will be taken, and when, where a new resident with an unusual presentation is admitted. In this case, Lugh had a diagnosis of Angelman’s syndrome with which staff were unfamiliar. Again, I asked to see a policy document setting out what training or other steps will now be taken in such circumstances and by when. ”
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 Bowden Derra Park Limited; that does not assign responsibility.
PFD Monitor interpretation
Delays in reviewing new residents’ Care Plans
Wider context from the report
“ii) Concern was raised that Care Plans for new residents were not reviewed sufficiently promptly. I asked to see a policy document setting out the expectation for healthcare professionals for how long it should take for a new resident’s Care Plan to be reviewed after admission. ”
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 Bowden Derra Park Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to continuously monitor residents
Wider context from the report
“i) I heard evidence at inquest that all residents were constantly monitored yet I found as fact that there were times when this did not happen for Lugh. I was informed that a new system has been put in place requiring staff to sign a form indicating the periods in time when they were responsible for monitoring residents. I asked for evidence to demonstrate this (a completed form) and for confirmation that, where there were any gaps in monitoring, these were explained on the form. ”
Open source report
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
Update the Care Plan Policy to define the expected timeframe for reviewing new residents’ care plans after admission.

Verbatim wording from the response
“ii. Concern was raised that Care Plans for new residents were not reviewed sufficiently promptly. I asked to see a policy document setting out the expectation for healthcare professionals for how long it should take for a new resident's Care Plan to be reviewed after admission.”

Source location
Response from Bowden Derra Park ltd
Page 1 · response
Published 22 March 2023
Open published response
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
Update the nocturnal CCTV monitoring chart to record monitoring periods and explain any gaps.

Verbatim wording from the response
“2. Updated Nocturnal CCTV Monitoring Chart”

Source location
Response from Bowden Derra Park ltd
Page 2 · response
Published 22 March 2023
Open published response
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
Update the Training Policy to specify training and other steps for new residents with unusual presentations.

Verbatim wording from the response
“iii. Concern was also raised about what steps will be taken, and when, where a new resident with an unusual presentation is admitted. In this case, Lugh had a diagnosis of Angelman's syndrome with which staff were unfamiliar. Again, I asked to see a policy document setting out what training or other steps will now be taken in such circumstances and by when.”

Source location
Response from Bowden Derra Park ltd
Page 1 · response
Published 22 March 2023
Open published response

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 raised3

Lack of training or other preparedness for new residents with unusual presentations

Delays in reviewing new residents’ Care Plans

Failure to continuously monitor residents

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.3

Actions described in response 3