Concerns raised 16 Failure to refer to a dietician View source Shortage of food and other equipment View source Use of a medically unqualified home manager View source Failure to follow up abnormal blood test results View source Delays in referral to Tissue Viability Nurses View source Lack of clear policies and procedures View source Failure to follow Tissue Viability Nurses advice View source Shortage of care staff View source Failure to involve District Nursing Teams View source Failure to refer to a physiotherapist View source Failure to provide an upgraded mattress View source Minimal GP involvement View source Failure to complete turning charts View source Use of an unregistered home manager View source Poor management and absences of management staff View source Failure to refer to mental health services View source See 13 more concerns
Responses linked to these concerns
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No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Norman Arthur BEARD · 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
Norman Arthur BEARD suffered a fall, was admitted to hospital, and later transferred to Daisy Bank Nursing Home, where he developed serious pressure sores, dehydration and significant weight loss. He died at Abbey Court Nursing Home on 14 February 2015. Concerns included delayed referral and inadequate treatment of pressure sores, shortages of staff and essential supplies, incomplete care records, inadequate response to weight loss and minimal GP involvement.
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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to refer to a dietician
Wider context from the report “(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician , physiotherapist, mental health services or involvement of District Nursing Teams.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Shortage of food and other equipment
Wider context from the report “(3) Financial difficulties led to shortage of staff, food and other equipment .
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Use of a medically unqualified home manager
Wider context from the report “(1) The home known as Daisy Bank Cheddle has now closed however there are three other care homes which remain under that same ownership of ████████ and managed by the same Chief Executive, Mr Tee.
(2) Poor management and absences of management staff was evident during the inquest. The home manager was not registered and was not medically qualified.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to follow up abnormal blood test results
Wider context from the report “(7) The involvement of the GP was minimal and there was no follow up when blood tests revealed an abnormality .
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to Tissue Viability Nurses
Wider context from the report “(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Lack of clear policies and procedures
Wider context from the report “(4) There were no clear policies and procedures in place.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to follow Tissue Viability Nurses advice
Wider context from the report “(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed . Turning charts were not filled in and an upgraded mattress was not provided.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Shortage of care staff
Wider context from the report “(3) Financial difficulties led to shortage of staff , food and other equipment.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to involve District Nursing Teams
Wider context from the report “(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician, physiotherapist, mental health services or involvement of District Nursing Teams .
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to refer to a physiotherapist
Wider context from the report “(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician, physiotherapist , mental health services or involvement of District Nursing Teams.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to provide an upgraded mattress
Wider context from the report “(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided .
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Minimal GP involvement
Wider context from the report “(7) The involvement of the GP was minimal and there was no follow up when blood tests revealed an abnormality.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to complete turning charts
Wider context from the report “(5) Mr Beard's deteriorating pressure ulcers were not referred to the Tissue Viability Nurses in a timely fashion and advice, once given, was not followed. Turning charts were not filled in and an upgraded mattress was not provided.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Use of an unregistered home manager
Wider context from the report “(1) The home known as Daisy Bank Cheddle has now closed however there are three other care homes which remain under that same ownership of ████████ and managed by the same Chief Executive, Mr Tee.
(2) Poor management and absences of management staff was evident during the inquest. The home manager was not registered and was not medically qualified.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Poor management and absences of management staff
Wider context from the report “(1) The home known as Daisy Bank Cheddle has now closed however there are three other care homes which remain under that same ownership of ████████ and managed by the same Chief Executive, Mr Tee.
(2) Poor management and absences of management staff was evident during the inquest. The home manager was not registered and was not medically qualified.
” 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 Care First Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to refer to mental health services
Wider context from the report “(6) Mr Beard lost a significant amount of weight. There was no referral to a dietician, physiotherapist, mental health services or involvement of District Nursing Teams.
” 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