Bowden Derra Park Limited

Private and voluntary organisations · Private limited company

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First report 13 Mar 2023•Latest report 13 Mar 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports
1

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
3

Across all linked responses

Stated actions
3

Described in responses

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.

  1. Cornwall and Isles of Scilly

    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
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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