Recipient

Coombe Dingle Nursing Home

Pin Request correction

First report 1 Dec 2013•Latest report 1 Dec 2013

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

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

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Surrey

    AI-generated summary

    John William Tugwell · 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 William Tugwell, a nursing-home resident aged 79, was found at the bottom of the stairs after an unwitnessed fall and later died from injuries including skull fractures and an extra cranial scalp haematoma. The principal concern was that, despite a documented history of previous falls, he had unsupervised access to two sets of stairs at the home.

    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 Coombe Dingle Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to restrict unsupervised access to stairs for vulnerable residents

    Wider context from the report

    “Although Mr Tugwell was clearly a falls risk given his documented history of previous falls at the home, he was allowed unsupervised access to the two sets of stairs at the home. I would be grateful if you could re consider the appropriateness of allowing such vulnerable and unsupervised residents access to the stairs given the potential for serious injury. ”
    Open source report
Back to top

Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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