Recipient

Bupa Care Homes

First report 31 Mar 2014•Latest report 9 Mar 2018

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Multi-service care provider. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 2
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 Bupa Care Homes linked to the concerns in each report. Select any concern, action or position to view the source wording.

9 Mar2018
Gloucestershire
Concerns raised2
1. Failure to define required levels of resident supervision in care plans and guidance
2. Failure to maintain required visual observation during resident supervision
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 Anthony Sketchley · 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 Anthony Sketchley, a resident of Ashley House Nursing Home, died after falling through a gap in a bariatric commode chair and sustaining a traumatic perianal injury. The report identified concerns about inadequate supervision, unclear care-plan requirements and definitions of supervision, and insufficient documented assessment of the commode’s suitability.

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 Bupa Care Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to define required levels of resident supervision in care plans and guidance
Wider context from the report
“At the time of the incident Mr Sketchley was to be supervised. The evidence that I heard was the main carer thought that whilst on the commode Mr Sketchley was to be supervised at all times. The care plan dictated that generally Mr Sketchley was to be supervised regularly. I heard no evidence that staff understood exactly what level of supervision was required. I heard from Demelza James that it is deemed acceptable to not observe / watch a resident who is being supervised but just to listen to them. I heard no evidence that Mr Sketchley’s care plan stated this was a sufficient level of supervision, nor that there are any guidelines to assist staff when making decisions about the level of supervision a resident requires. ”
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 Bupa Care Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain required visual observation during resident supervision
Wider context from the report
“At the time of the incident Mr Sketchley was to be supervised. The evidence that I heard was the main carer thought that whilst on the commode Mr Sketchley was to be supervised at all times. The care plan dictated that generally Mr Sketchley was to be supervised regularly. I heard no evidence that staff understood exactly what level of supervision was required. I heard from Demelza James that it is deemed acceptable to not observe / watch a resident who is being supervised but just to listen to them. I heard no evidence that Mr Sketchley’s care plan stated this was a sufficient level of supervision, nor that there are any guidelines to assist staff when making decisions about the level of supervision a resident requires. ”
Open source report
31 Mar2014
London (East)
Concerns raised5
1. Inadequacy of investigation documentation following a safety incident
2. Failure of nursing staff to establish a fallen patient’s medical and medication history
3. Failure to carry out directed neurological and physical observations after a fall
1. Failure to appropriately record post-fall checks in clinical records
2. Failure to ensure awareness of bleeding risk after head injury in elderly patients taking warfarin
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

Roy Joseph Godfrey · 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

Roy Joseph Godfrey, a 71-year-old resident of a residential care home, suffered an unwitnessed fall and head injury while taking long-term warfarin. He was later found unresponsive and died from a fatal subdural haematoma. Concerns included insufficient awareness of the bleeding risk associated with head injury and warfarin, inadequate overnight neurological checks and recording, and shortcomings in the care home's investigation documentation.

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 Bupa Care Homes; that does not assign responsibility.
PFD Monitor interpretation
Inadequacy of investigation documentation following a safety incident
Wider context from the report
“7. I heard a great deal of evidence from the London Ambulance Service in relation to a thorough investigation they had conducted into this case. They had the assistance of an independent clinical advisor and had identified all of the relevant issues. They had taken all of the action required to address those issues. BUPA Care Homes however had provided a one page document headed “Summary of Investigation”. This was the only investigation document ”
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 Bupa Care Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing staff to establish a fallen patient’s medical and medication history
Wider context from the report
“5. The Deputy Manager confirmed that the qualified member of staff who attended when Mr Godfrey sustained his fall should have been aware of the increased risk of bleeding as a result of the long term warfarin. She confirmed that he may not have had access to the medication chart. It is my view that a qualified member of the nursing staff who attends a patient who has suffered a fall should make themselves aware of both the patient’s medical history and medication history. ”
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 Bupa Care Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to carry out directed neurological and physical observations after a fall
Wider context from the report
“2. The staff at the care home accepted the responsibility of Mr Godfrey’s care following the paramedic’s assessment. They agreed to observe Mr Godfrey during the night. The actual checks carried out by the staff were not in accordance with the direction given by the paramedic. The senior care worker confirmed that she did not examine the swelling or check for alertness. 3. The Deputy Manager who gave evidence at the inquest confirmed that the checks carried out by the staff were not in her view appropriate. She would have expected the pupils to have been checked and checks to ensure that the patient was alert and orientated. ”
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 Bupa Care Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to appropriately record post-fall checks in clinical records
Wider context from the report
“4. The Deputy Manager who gave evidence confirmed that the checks that were carried out on Mr Godfrey were not appropriately recorded in the clinical records. ”
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 Bupa Care Homes; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure awareness of bleeding risk after head injury in elderly patients taking warfarin
Wider context from the report
“1. Mr Godfrey was an elderly patient who was at risk of falling and who was on long term warfarin. There is an increased risk of bleeding to elderly patients on warfarin who sustain a head injury. Neither the care staff who attended to Mr Godfrey on the evening of the 23rd July 2013 or the paramedic appeared to have been aware of the increased risk of such bleeding in an elderly patient who had sustained a minor head injury. The inquest heard clear evidence from the London Ambulance Service in relation to further training that was to be provided to their staff in relation to this risk. In addition, amendments are to be considered to the LAS guidance, to highlight this risk to all staff. ”
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 raised2

Failure to define required levels of resident supervision in care plans and guidance

Failure to maintain required visual observation during resident supervision

Concerns raised5

Inadequacy of investigation documentation following a safety incident

Failure of nursing staff to establish a fallen patient’s medical and medication history

Failure to carry out directed neurological and physical observations after a fall

Failure to appropriately record post-fall checks in clinical records

Failure to ensure awareness of bleeding risk after head injury in elderly patients taking warfarin