Recipient

Court Nursing Home

First report 16 Jan 2021•Latest report 16 Jan 2021

Recipient record

Reports, concerns and published responses

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

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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

16 Jan2021
Nottinghamshire
Concerns raised8
1. Failure to update general health and mobility care plans
2. Failure to regularly document repositioning
3. Failure to recognise serious and deteriorating medical conditions
1. Delays in organising medical assistance for serious deterioration
2. Failure of management to understand how and why repositioning deficiencies occurred
3. Failure to recognise changing health and mobility needs
4. Failure to maintain an updated skin integrity care plan
5. Failure to conduct robust management review following a death
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Norma Lockton · 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

Norma Lockton was a resident in a nursing home whose reduced mobility and vulnerable skin required care measures that were not followed. She developed a wound behind her left knee, which became infected and led to cellulitis and systemic sepsis; medical assistance was not sought until her condition was life threatening, and she died in hospital on 4 March 2020. The principal concerns included failures in skin care planning and implementation, repositioning, recognition of changing care needs and deteriorating health, and management review following the 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 Court Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to update general health and mobility care plans
Wider context from the report
“3. The lack of recognition of Norma’s changing health and mobility needs, leading to no change in her general health and mobility care plans ”
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 Court Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to regularly document repositioning
Wider context from the report
“2. The lack of regular documented repositioning of Norma, with no understanding by the management team as to how and why this issue had occurred. ”
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 Court Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise serious and deteriorating medical conditions
Wider context from the report
“4. The lack of recognition of a serious and deteriorating medical condition (that of cellulitis), leading to no medical assistance being organised until the situation was life threatening. ”
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 Court Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Delays in organising medical assistance for serious deterioration
Wider context from the report
“4. The lack of recognition of a serious and deteriorating medical condition (that of cellulitis), leading to no medical assistance being organised until the situation was life threatening. ”
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 Court Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of management to understand how and why repositioning deficiencies occurred
Wider context from the report
“2. The lack of regular documented repositioning of Norma, with no understanding by the management team as to how and why this issue had occurred. ”
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 Court Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to recognise changing health and mobility needs
Wider context from the report
“3. The lack of recognition of Norma’s changing health and mobility needs, leading to no change in her general health and mobility care plans ”
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 Court Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain an updated skin integrity care plan
Wider context from the report
“1. The lack of an updated skin integrity care plan, with little understanding by the management as to why there had been no update to it following the clear District Nurse instructions regarding skin care. ”
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 Court Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to conduct robust management review following a death
Wider context from the report
“5. The lack of robust review by the management team following a death. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised8

Failure to update general health and mobility care plans

Failure to regularly document repositioning

Failure to recognise serious and deteriorating medical conditions

Delays in organising medical assistance for serious deterioration

Failure of management to understand how and why repositioning deficiencies occurred

Failure to recognise changing health and mobility needs

Failure to maintain an updated skin integrity care plan

Failure to conduct robust management review following a death