13 Sep 2022 Mr Peter Antony Joseph Pearson · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 11 Delays in calling an ambulance when a resident’s condition requires emergency assistance View source Failure to maintain records of medications dispensed to residents View source Failure to record required twice-daily oral-cavity checks View source Ineffective investigation of resident deaths View source Failure to ensure effective supervision of nursing staff View source Failure to materially improve senior management oversight of the Registered Manager and deputy manager View source Failure to improve record keeping and record retention View source Failure to provide accurate and comprehensive audit information View source Shortcomings in senior management oversight of the Registered Manager View source Failure to ensure that all medications are recorded View source Failure to complete nursing records of residents’ medical conditions View source See 8 more concerns
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AI-generated summary
Mr Peter Antony Joseph Pearson · 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
Mr Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.
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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Delays in calling an ambulance when a resident’s condition requires emergency assistance
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity .
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain records of medications dispensed to residents
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity.
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to record required twice-daily oral-cavity checks
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity.
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Ineffective investigation of resident deaths
Wider context from the report “(3) It is accepted on behalf of the Home that there was an “ineffective investigation” into Mr Pearson’s death by the Home . Responsibility for that cannot not solely be attributed to the former Registered Manager.
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure effective supervision of nursing staff
Wider context from the report “(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff .
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to materially improve senior management oversight of the Registered Manager and deputy manager
Wider context from the report “(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially . Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff.
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to improve record keeping and record retention
Wider context from the report “(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff.
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide accurate and comprehensive audit information
Wider context from the report “(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection ”. It is accepted by senior management that there were “shortcomings” in oversight of this manager. The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded.
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Shortcomings in senior management oversight of the Registered Manager
Wider context from the report “(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection”. It is accepted by senior management that there were “shortcomings” in oversight of this manager . The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded.
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that all medications are recorded
Wider context from the report “(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection”. It is accepted by senior management that there were “shortcomings” in oversight of this manager. The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded .
” 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 Corbett House Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to complete nursing records of residents’ medical conditions
Wider context from the report “(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day . Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity.
” 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