Concerns raised 12 Failure to conduct an adequate safeguarding enquiry View source Failure to inform family about CQC enquiries View source Failure to obtain independent evidence about care View source Failure to refer infected pressure sores to a general practitioner View source Failure to keep accurate care records View source Inadequate tissue viability nurse service capacity View source Failure to incorporate tissue viability advice into care plans View source Failure to involve family in safeguarding review View source Failure to produce an adequate s42 report View source Failure to provide accurate information about tissue viability nurse involvement View source Failure to follow tissue viability advice on turning and dressing sores View source Failure to inform family about developed pressure sores View source See 9 more concerns
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AI-generated summary
Ronald Arthur Farrington · 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
Ronald Arthur Farrington, who had dementia and Parkinson’s disease and was resident in a nursing home, developed infected sacral pressure sores. He was admitted to hospital with sepsis and died on 21 June 2016; the inquest recorded sepsis caused by infection in the pressure sore, with pneumonia contributing. The substantive concerns included failures to follow and record tissue-viability advice, failure to refer the infection to his general practitioner, inadequate tissue-viability nurse availability, and insufficient independent investigation by the CQC and safeguarding review.
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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct an adequate safeguarding enquiry
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family about CQC enquiries
Wider context from the report “4. Mr Farrington’s family who visited him on a very regular basis and could have provided information about his care were not made aware that he had developed pressure sores, nor that the CQC were conducting any enquiries.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain independent evidence about care
Wider context from the report “3. The CQC did not obtain independent evidence about Mr Farrington’s care having received 2 notifications that he had developed pressure sores.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to refer infected pressure sores to a general practitioner
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to keep accurate care records
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Inadequate tissue viability nurse service capacity
Wider context from the report “2. Only one tissue viability nurse was employed by First Community Care from March 2016 onwards. They were on annual leave for 6 weeks between the 18th March and the 15th June 2016. This was not an adequate level of service.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate tissue viability advice into care plans
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to involve family in safeguarding review
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to produce an adequate s42 report
Wider context from the report “5. A large scale review has been convened as a result of the safeguarding alert raised by East Surrey Hospital. It is now being conducted by Surrey Adult Safeguarding. As at the date of the resumed inquest no adequate s42 report has been written. The family have not been invited to take part in the review. No adequate enquiry has been made.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate information about tissue viability nurse involvement
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to follow tissue viability advice on turning and dressing sores
Wider context from the report “1. Nuffield Care Centre:
a.) Failed to incorporate all the advice given by the tissue viability nurses in Mr Farrington’s care plans.
b.) Failed to keep accurate records.
c.) Informed the CQC that the tissue viability nurses were still involved with Mr Farrington when they weren’t.
d.) Failed to follow the advice of the tissue viability nurses as to turning and how to dress Mr Farrington’s sores
e.) Failed to refer Mr Farrington to his General Practitioner when he developed an infection in the sacral pressure sore on the 1st June 2016.
” 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 Community Health Care; that does not assign responsibility.
PFD Monitor interpretation Failure to inform family about developed pressure sores
Wider context from the report “4. Mr Farrington’s family who visited him on a very regular basis and could have provided information about his care were not made aware that he had developed pressure sores , nor that the CQC were conducting any enquiries.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations