Recipient

Cambridge Nursing Home LtdIncludes reports addressed to a minister or senior office-holder acting for this organisation.

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First report 26 Mar 2024•Latest report 26 Mar 2024

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

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 Cambridge Nursing Home Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: ████████, Managing Director, The Cambridge Nursing Home Ltd.

    East London

    AI-generated summary

    Mark Wolfe Kinzley · 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

    Mark Wolfe Kinzley, a 61-year-old man with a neurological disorder, mental health problems and a history of self-harm, was found unresponsive at his nursing home on 30 October 2023 after suspending himself by a coat hanger. He died in hospital on 1 November 2023 from complications of the injuries sustained at the nursing home. The concerns included whether the care setting was appropriate, the absence of a formal capacity assessment, and the lack of a mental health assessment despite his history and deteriorating mental state.

    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 Cambridge Nursing Home Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of formal capacity assessment for nursing-home residents

    Wider context from the report

    “2. No formal assessment of Mr Kinzley’s capacity was undertaken whilst a resident at the nursing home. Such an assessment may have resulted in an advocate acting as his voice in his best interests. ”
    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 Cambridge Nursing Home Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to refer residents for mental health assessment when indicated by mental illness, self-harm history or deteriorating mental state

    Wider context from the report

    “3. During the same period, Mr Kinzley was not referred for a mental health assessment despite. a. His history of mental illness. b. His history of deliberate self-harm. c. His history of accidental self-harm when agitated. d. His deteriorating mental state during the month prior to his death. ”
    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 Cambridge Nursing Home Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Inappropriate location of care for a socially isolated adult with profound neurological disorder and mental illness

    Wider context from the report

    “1. I have doubts that the location of Mr Kinzley’s care was appropriate. Mr Kinzley was a socially isolated adult suffering from a profound neurological disorder and mental illness. ”
    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