Clarendon Nursing Home

Private and voluntary organisations · Nursing home

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First report 28 Feb 2019•Latest report 28 Feb 2019

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

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

  1. South London

    AI-generated summary

    Yong Keng Hong · 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

    Yong Keng Hong, an asylum seeker with very little English, was transferred from hospital to a care home after displaying self-harm and suicidal behaviour. Despite advice for constant observations and an immediate mental health referral, the observation regime was not implemented, no interpreter or risk assessment was arranged, and his call bell was returned; he used it to hang himself from a curtain rail on 12 July. Concerns included failures in observation, communication, risk assessment, clinical follow-up and staff training.

    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 Clarendon Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to seek further advice from an appropriate clinician

    Wider context from the report

    “(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
    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 Clarendon Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to implement the advised observation regime

    Wider context from the report

    “(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
    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 Clarendon Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide therapeutic engagement

    Wider context from the report

    “(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
    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 Clarendon Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to carry out a risk assessment before returning the call bell

    Wider context from the report

    “(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
    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 Clarendon Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain interpreter support for assessment of needs

    Wider context from the report

    “(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
    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 Clarendon Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of training for care home staff in carrying out risk assessments

    Wider context from the report

    “(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
    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 Clarendon Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide a safety net

    Wider context from the report

    “(1) His GP made an immediate referral to mental health services and advised constant observations, however: (a) the observation regime advised by the GP was not implemented (b) whilst awaiting a formal review of his mental state, no interpreter was sought in the meantime to assist with assessment of his needs due to issues of confusion between the social work team and the care home about responsibility for funding (c) no risk assessment was carried out prior to making the decision to return his call bell. (2) No further advice was sought from the GP or other appropriate clinician and he was left in social isolation without any means to express his distress, no safety net and no therapeutic engagement (3) Evidence at the inquest was that care home staff did not receive training in how to carry out risk assessments ”
    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

Data last updated 7 September 2026