1 Aug 2025 Margaret Dorothy MEDLICOTT · Prevention of Future Deaths report Worcestershire
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Concerns raised 4 Failure to complete proper risk assessments and care plans for risks to residents and others View source Lack of proper staff training in risk assessment and care planning View source Failure to provide a working environment that enables staff to question unsafe decisions View source Failure to ensure that admissions are clinically assessed and comply with agreed restrictions View source See 1 more concern
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. 6
Action
Require monthly sample audits and random spot checks of care documentation and delivered care, with action plans addressing audit findings.
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Action
Require Home Manager or Deputy Manager oversight and structured pre-admission assessment before accepting new residents.
View source
Action
Implement PCS as an integrated electronic system for care plans, risk assessments, task alerts and management oversight.
View source
Action
Train staff in PCS and mandatory care-documentation subjects, with refresher or repeat training where standards are not met.
View source
Action
Complete organisation-wide audits of care documentation to establish baselines and identify lessons for training, tools, governance and further audit scheduling.
View source
Action
Provide and disseminate whistleblowing and speak-up policies, escalation contacts, open-door access and shift-based opportunities to raise concerns.
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AI-generated summary
Margaret Dorothy MEDLICOTT · 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
Margaret Dorothy Medlicott, who lived with dementia, sustained a severe head injury after being deliberately pushed by another resident at Haresbrook Park Care Home on 23 April 2020. She died in hospital from complications of that injury on 3 May 2020. Concerns included the admission of residents despite agreed restrictions, failures to complete proper risk assessments and care plans, and whether staff were trained and supported to question unsafe decisions.
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× 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 Capital Care Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to complete proper risk assessments and care plans for risks to residents and others
Wider context from the report “2) Despite being aware of concerns about the behaviour of both Mrs. Medlicott and the other resident both before and shortly after their respective admissions to the care home, staff there failed to complete proper risk assessments and care plans addressing the risks posed by each of them to themselves and to others . Those failures were accepted, but the inquest heard no satisfactory explanation as to why they might have occurred. There is therefore concern that the staff concerned, and perhaps other staff at the care home, have not received proper training in how to carry out these important tasks.
” 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 Capital Care Group Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of proper staff training in risk assessment and care planning
Wider context from the report “2) Despite being aware of concerns about the behaviour of both Mrs. Medlicott and the other resident both before and shortly after their respective admissions to the care home, staff there failed to complete proper risk assessments and care plans addressing the risks posed by each of them to themselves and to others. Those failures were accepted, but the inquest heard no satisfactory explanation as to why they might have occurred. There is therefore concern that the staff concerned, and perhaps other staff at the care home, have not received proper training in how to carry out these important tasks .
” 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 Capital Care Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a working environment that enables staff to question unsafe decisions
Wider context from the report “1) The resident whose actions caused Mrs. Medlicott’s fatal head injury had a clear and recent history of unpredictable physical aggression towards his wife. The decision to admit that resident to the care home was made by a member of senior management without the clinical qualifications to assess whether the care home could meet his care needs, and was in clear breach of a restriction agreed by the care home with Worcestershire County Council that no person was to be admitted who presented with “physically challenging behaviour”. Despite having concerns about the decision to admit him, no member of staff at the care home felt able to raise or question that decision with senior management . There is therefore a concern that staff at the care home may not understand that it is their professional duty to question such decisions , and that the care home is not providing a working environment which encourages them to do so ;
” 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 Capital Care Group Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that admissions are clinically assessed and comply with agreed restrictions
Wider context from the report “1) The resident whose actions caused Mrs. Medlicott’s fatal head injury had a clear and recent history of unpredictable physical aggression towards his wife. The decision to admit that resident to the care home was made by a member of senior management without the clinical qualifications to assess whether the care home could meet his care needs , and was in clear breach of a restriction agreed by the care home with Worcestershire County Council that no person was to be admitted who presented with “physically challenging behaviour” . Despite having concerns about the decision to admit him, no member of staff at the care home felt able to raise or question that decision with senior management. There is therefore a concern that staff at the care home may not understand that it is their professional duty to question such decisions, and that the care home is not providing a working environment which encourages them to do so;
” Open source report
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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 Require monthly sample audits and random spot checks of care documentation and delivered care, with action plans addressing audit findings.
Verbatim wording from the response “Each Home conducts its own internal audits on care documentation. Each Home Manager is responsible for managing how its Home completes its oversight. At Haresbrook Park Care Home, the Care Team Leaders are responsible for overseeing the care plans on their unit. Every month, they will be required to conduct an audit on a sample of care plans on the alternate unit. The results of these audits will be shared with the Home Manager who will compose an action plan to be addressed by the next month's audit. The Care Team Leaders are also responsible for conducting random spot checks on both documentation and on the floor care.” Source location Response from Capital Care Group
Open published response
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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 Require Home Manager or Deputy Manager oversight and structured pre-admission assessment before accepting new residents.
Verbatim wording from the response “The Regional Manager sits within Head Office and is the direct contact for any of the Home's to escalate concerns to senior management.” Source location Response from Capital Care Group
Open published response
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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 Implement PCS as an integrated electronic system for care plans, risk assessments, task alerts and management oversight.
Verbatim wording from the response “The Home is now benefitting from a fully integrated electronic care system, namely PCS (Person-Centred Software). The maintaining of care documentation, including risk assessments, in one place allows for one point of reference for all members of staff.” Source location Response from Capital Care Group
Open published response
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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 Train staff in PCS and mandatory care-documentation subjects, with refresher or repeat training where standards are not met.
Verbatim wording from the response “All staff are trained on PCS at their induction. This training is conducted by review of videos and use of the system in 'TUTOR' mode.” Source location Response from Capital Care Group
Open published response
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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 Complete organisation-wide audits of care documentation to establish baselines and identify lessons for training, tools, governance and further audit scheduling.
Verbatim wording from the response “To ensure organisation oversight, the organisation's compliance manager is completing a full audit of all Homes care documentation. This was completed for Haresbrook Park Care Home on 22 August 2025. The results have been shared with the Home Manager and all staff will be addressed at a mandatory Home-wide meeting on 24 September 2025. Beyond organisation oversight, the audit has allowed the compliance manager to obtain each Home's baseline and then work to generate an” Source location Response from Capital Care Group
Open published response
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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 Provide and disseminate whistleblowing and speak-up policies, escalation contacts, open-door access and shift-based opportunities to raise concerns.
Verbatim wording from the response “QCS, an external provider, produces all of the Home's policies. The contract includes the routine review, update and distribution of the documents to ensure they remain in line with regulations, care standards and internal expectations. The Policies include Raising Concerns, Freedom to Speak Up and Whistleblowing Policies. These are all fit for purpose and are available to all staff on the electronic policies and procedures platform. The platform also produces a reading list for all managers to outline which staff have engaged with the Policy. Any staff failing to review the policies will be reminded of their importance and their professional obligations to consider, and adhere, to the documentation. Any continued shortfalls will be escalated.” Source location Response from Capital Care Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing electronic systems, training, audits and governance are considered sufficient to support robust risk assessments and care documentation.
Verbatim wording from the response “The Home is now benefitting from a fully integrated electronic care system, namely PCS (Person-Centred Software). The maintaining of care documentation, including risk assessments, in one place allows for one point of reference for all members of staff.” Source location Response from Capital Care Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation The current management structure and pre-admission assessment process are considered sufficient to ensure admissions are safely assessed and overseen.
Verbatim wording from the response “The Regional Manager sits within Head Office and is the direct contact for any of the Home's to escalate concerns to senior management.” Source location Response from Capital Care Group
Open published response
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Existing policies, escalation routes and speaking-up practices are considered sufficient to equip staff to raise and escalate concerns.
Verbatim wording from the response “QCS, an external provider, produces all of the Home's policies. The contract includes the routine review, update and distribution of the documents to ensure they remain in line with regulations, care standards and internal expectations. The Policies include Raising Concerns, Freedom to Speak Up and Whistleblowing Policies. These are all fit for purpose and are available to all staff on the electronic policies and procedures platform. The platform also produces a reading list for all managers to outline which staff have engaged with the Policy. Any staff failing to review the policies will be reminded of their importance and their professional obligations to consider, and adhere, to the documentation. Any continued shortfalls will be escalated.” Source location Response from Capital Care Group
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