Concerns raised 9 Failure to escalate and respond to prolonged inadequate fluid intake View source Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine View source Failure to secure patients safely in wheelchairs View source Failure to provide adequate clothing for patients unable to dress themselves View source Failure to encourage patients to drink or eat when intake is inadequate View source Failure to provide consistent toileting and continence care View source Failure to consistently encourage sufficient drinking and eating View source Failure to monitor patients in communal areas View source Inaccurate recording of patients’ fluid intake View source See 6 more concerns
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AI-generated summary
John Francis GREGORY · 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
John Francis Gregory died after developing acute kidney injury associated with low oral fluid intake, in the context of Alzheimer’s disease and old age. Concerns included inadequate encouragement and monitoring of drinking in hospital rehabilitation and residential care, inaccurate fluid-intake records, and failures to escalate or respond to his deterioration at Muriel Street Resource Centre.
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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 Care UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate and respond to prolonged inadequate fluid intake
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am . The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this .
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.
This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.
” 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 UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff.
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet; on more than one occasion his family found him in wet bedclothes; and he was put to bed at 7.30pm to fit in with nursing routine .
” 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 UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to secure patients safely in wheelchairs
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff.
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests . He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself.
” 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 UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide adequate clothing for patients unable to dress themselves
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff.
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks . By then Mr Gregory was not capable of dressing himself .
” 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 UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to encourage patients to drink or eat when intake is inadequate
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him.
This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat .
” 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 UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistent toileting and continence care
Wider context from the report “1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff .
On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet ; on more than one occasion his family found him in wet bedclothes ; and he was put to bed at 7.30pm to fit in with nursing routine.
” 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 UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently encourage sufficient drinking and eating
Wider context from the report “2. His oral fluid intake was considered by Evergreen Ward, and steps were taken to address this, but the intake recorded on his charts demonstrate that it remained too low .
Maintaining sufficient fluid intake was a challenge, but there is the possibility that not every member of staff encouraged him to drink and eat in the way the sister in charge did.
” 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 UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Failure to monitor patients in communal areas
Wider context from the report “3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff .
He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself.
” 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 UK Community Partnerships Ltd; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of patients’ fluid intake
Wider context from the report “4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia.
On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm.
The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this.
His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him .
This demonstrates that the chart was inaccurate . It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat.
” 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 Roll out Restore2 deterioration monitoring, placing records in care plans and requiring monthly nursing updates.
Verbatim wording from the response “To supplement this, since April 2020, Muriel Street has also rolled out the Restore2 deterioration tool (which is based upon the NEWS2 system commonly used across actual hospitals). A copy of the Restore2 documentation is attached and is contained within each resident's care plan file, and updated monthly by a nurse. The Restore tool assists staff members to be able to recognise the early signs that a resident may be deteriorating (as per the Significant 7 course), and then guides nursing staff on appropriate escalation and frequency of monitoring if required to ensure a resident is provided with timely and appropriate medical intervention. It should also be noted that the tool recognises that not all residents are the same, and therefore there is the ability to record additional signs of possible deterioration specific to a resident.” Source location 2020-0073-Response-from-Care-UK_Redacted
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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 Disseminate wheelchair-safety guidance through laminated copies at nurses’ stations and copies in relevant resident care-plan folders.
Verbatim wording from the response “Further, there is now a laminated copy of this guide at every nurse's station to ensure that the guide is easily accessible. Additionally, where a resident's care plan requires the use of a wheelchair, a hard copy of the guide is placed into that resident's care plan folder in their room.” Source location 2020-0073-Response-from-Care-UK_Redacted
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 full-group refresher training on wheelchair safety, appropriate dressing, oral-fluid encouragement and updated welfare-check documentation after restrictions are lifted.
Verbatim wording from the response “As is clear from the above, there has been a number of changes made since the death. Ordinarily group training would be provided in order to re-inforce the improvements made. However, given the current pandemic, this has not been possible, and training has instead taken place in smaller groups. Notwithstanding this, once the current restrictions have been lifted, it is the intention of Muriel Street to have full group training on the following relevant areas:” Source location 2020-0073-Response-from-Care-UK_Redacted
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 Increase staffing and senior oversight on each floor by adding senior managers and team-leader walkarounds.
Verbatim wording from the response “Muriel Street has also increased staffing levels since this incident, and there is now an increased senior presence on each floor with a senior manager (Deputy Manager, Clinical Lead or Care lead) based in each nursing office and the addition of a team leader who supports to carry out regular walk arounds of their floor / unit. The result of this is greater oversight of staff activities and monitoring of residents to ensure that residents' needs and safety are maintained.” Source location 2020-0073-Response-from-Care-UK_Redacted
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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 Deliver mandatory room-based training on encouraging oral-fluid intake and refresher techniques after pandemic restrictions are lifted.
Verbatim wording from the response “Additionally, once the current restrictions in place due to the pandemic are lifted, Muriel Street will be undertaking mandatory training on room training for staff, part of which provides training to staff on the need to encourage residents to increase oral intake generally, as well as refreshing techniques / methods to encourage residents to do the same.” Source location 2020-0073-Response-from-Care-UK_Redacted
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 Deliver a personal-care refresher course addressing appropriate resident dressing after pandemic restrictions are lifted.
Verbatim wording from the response “It is the firm intention of Muriel Street that all staff will undergo a personal care training refresher course once the current pandemic and consequent lifting on restrictions allow.” Source location 2020-0073-Response-from-Care-UK_Redacted
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 daytime documented welfare checks and audit completion through the Home Manager’s daily random documentation checks.
Verbatim wording from the response “Muriel Street also undertakes specific welfare checks upon residents at regular intervals throughout the day. Previously, whilst such checks would have been undertaken during the day as part of other care provision (e.g. during meal provision, or regular repositioning), there would be no separate documentation during daytimes. Having reviewed matters, since April 2020, in accordance with Care UK policy Muriel Street has now ensured that the welfare check sheets are completed during the day alongside the other documentation to food and fluid charts, activities log books, turning charts and daily notes in addition to at night where they were previously completed.” Source location 2020-0073-Response-from-Care-UK_Redacted
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 Reinforce appropriate-dress requirements through senior meetings, handovers, wardrobe posters and care-plan documentation reminders.
Verbatim wording from the response “Since this incident, the requirement to ensure that resident's are appropriately dressed was specifically discussed during the daily "Take 10" meetings for senior staff, and during handovers when all other staff would attend. During these meetings, posters, which are now placed in each resident's wardrobe, outlining examples ways in which a resident may wish to be dressed depending upon the weather, drawing upon the circumstances of Mr Gregory as an example of an unacceptable standard of care. Further, staff were reminded of the requirement to document any issues with clothing (e.g. non-compliance) within a resident's care plan file.” Source location 2020-0073-Response-from-Care-UK_Redacted
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 Introduce clearer fluid-balance and fluid-target charts, train staff in their use, and include them in documentation audits.
Verbatim wording from the response “Muriel Street has reviewed the fluid charts used and has introduced new fluid balance monitoring documentation – copies attached. The new charts are clearer and enable details of a resident's input / output to be recorded in more detail. Further, staff are now instructed to document when the re-attempt to provide oral fluids to ensure that there is evidence of active encouragement.” Source location 2020-0073-Response-from-Care-UK_Redacted
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 Strengthen wheelchair-safety training with dedicated guidance and complete one-to-one supervision sessions for all staff.
Verbatim wording from the response “Notwithstanding this, since Mr Gregory’s sad death, Muriel Street has reviewed the manual handling training provided. Following this, it was identified that the training surrounding the use of wheelchairs could be strengthened. Consequently, the training has been improved, and the manual handling training now includes a specific section on wheelchair safety guidance. This includes highlighting and working through the "How to Guide – Wheelchair safety Guidance" (copy attached) during the training session. Due to the current pandemic, and the consequent restrictions placed upon the ability to provide group training, Muriel Street has undertaken 1:1 supervision / training sessions with all staff members in order to go through the how to guide, and ensure staff are familiar with the expectations set out therein.” Source location 2020-0073-Response-from-Care-UK_Redacted
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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 Educate staff about encouraging oral-fluid intake through meetings and provide hydration guidance in resident care-plan folders.
Verbatim wording from the response “Since the death, Muriel Street has started and continues to educate staff of the need to encourage residents with oral intake of fluids. This has been done during "Take 10" and handover meetings. During these meetings all staff have been advised of the reasons why encouragement of oral fluids is so important, followed by an explanation and discussion of the ways of working and how to guides. Further, hard copies of these guides are now included in the resident’s care plan file in their room. This provides easier staff access to the guides and serves as a constant reminder to staff of the importance to encourage oral fluid intake.” Source location 2020-0073-Response-from-Care-UK_Redacted
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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 incident occurred on arrival at Muriel Street, not during hospital readmission, and the resident was neither in public nor unresponsive.
Verbatim wording from the response “For completeness, our understanding of the evidence, supported by the documentation from the family, is that the incident when Mr Gregory was found unsecured in a wheelchair was on arrival at Muriel Street, and not on the day he was readmitted to hospital. Further, our understanding of the evidence is that Mr Gregory was not in a public place, nor was he unresponsive at this time. That said, he should have been transferred into an armchair in his room.” Source location 2020-0073-Response-from-Care-UK_Redacted
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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 Acute concerns about a resident’s oral fluid intake should be referred to the visiting GP for consideration and advice.
Verbatim wording from the response “at weekly clinical review meetings). Further, in the event of more acute concerns in relation to oral fluid intake, the matter should be raised with the visiting GP to consider and advise, as occurred in Mr Gregory’s case.” Source location 2020-0073-Response-from-Care-UK_Redacted
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations