Concerns raised 12 Unclear documentation of falls, symptoms and measures taken to seek medical input View source Lack of policies for reporting concerns View source Inability of care home staff to meet residents’ care needs View source Failure to closely monitor medical conditions and follow escalation policies View source Failure to appropriately escalate concerns to Adult Social Care View source Failure to adequately manage and monitor breast infection View source Failure to carry out regular blood tests View source Unavailability of a system for actioning discharge summaries View source Lack of escalation policies View source Failure to document capacity appropriately in care plans View source Failure to record steps taken to support decision-making View source Lack of medication policies View source See 9 more concerns
Responses linked to these concerns
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AI-generated summary
Pamela George · 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
Pamela George, aged 70, died at Derriford Hospital on 30 June 2023 after being urgently admitted with suspected sepsis. The report identified missed opportunities to carry out required blood tests, manage a breast infection, document and escalate a fall and medical concerns, assess and record capacity, and maintain relevant care-home policies and records.
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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Unclear documentation of falls, symptoms and measures taken to seek medical input
Wider context from the report “4. The documentation surrounding the fall, the symptoms seen and measures taken to seek medical input were not clear .
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Lack of policies for reporting concerns
Wider context from the report “6. There was little or no evidence of policies in place generally at the home and in particular on medication, escalation and reporting of concerns .
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Inability of care home staff to meet residents’ care needs
Wider context from the report “3. It is likely that Miss George’s needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home’s ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen. The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss George being removed to another provider.
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to closely monitor medical conditions and follow escalation policies
Wider context from the report “3. It is likely that Miss George’s needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home’s ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen . The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss George being removed to another provider.
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately escalate concerns to Adult Social Care
Wider context from the report “3. It is likely that Miss George’s needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home’s ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen. The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss George being removed to another provider.
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately manage and monitor breast infection
Wider context from the report “2. The infection which caused her sepsis was a bacterial infection which ████████ told me could only have been successfully treated with antibiotics. I am not satisfied that the breast infection was adequately managed at Cann House it being noted that there was no record of how the breast infection was progressing between 25th May and 27th June 2023 .
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out regular blood tests
Wider context from the report “1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed.
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a system for actioning discharge summaries
Wider context from the report “1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed .
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation policies
Wider context from the report “6. There was little or no evidence of policies in place generally at the home and in particular on medication, escalation and reporting of concerns .
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to document capacity appropriately in care plans
Wider context from the report “5. There was little or no evidence that capacity had been appropriately documented with care plans remaining silent on the issue and records not analysing carefully what steps had been taken to help Miss George make decisions.
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to record steps taken to support decision-making
Wider context from the report “5. There was little or no evidence that capacity had been appropriately documented with care plans remaining silent on the issue and records not analysing carefully what steps had been taken to help Miss George make decisions .
” 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 Cann House Care Home; that does not assign responsibility.
PFD Monitor interpretation Lack of medication policies
Wider context from the report “6. There was little or no evidence of policies in place generally at the home and in particular on medication , escalation and reporting of concerns .
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations