Recipient

Cygnet Newton House

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First report 30 Oct 2015•Latest report 30 Oct 2015

Recipient record

Reports, concerns and published responses

Health and care · Healthcare site. 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 Cygnet Newton House linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Blackpool and the Fylde

    AI-generated summary

    Dennis Peter Stark · 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

    Dennis Peter Stark, who was detained at a rehabilitation unit, was found unresponsive in his second-floor bedroom on 27 May 2014 and later died after developing pneumonia and hypoxic brain injury. The report raised concerns that the absence of a lift and the difficulty of removing a person of his size from the second floor could delay emergency treatment and pose a risk to future patients requiring urgent medical attention.

    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 Cygnet Newton House; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of suitable means for safely removing people requiring urgent medical attention from second-floor accommodation

    Wider context from the report

    “1. During the course of the Inquest I heard evidence from a Paramedic Reynolds who had been called to Regency House (now Newton House) which is a rehabilitation unit that cares for individuals with mental health issues, Mr Stark having previously been diagnosed as suffering from schizophrenia. He was an obese gentleman who weighed in excess of 30 stones, and he had been found unresponsive in his room. He was residing in a second floor room at the premises. The premises have no lift. The Paramedic indicated that after her arrival, there followed a period of time during which Mr Stark had no pulse and required Cardio Pulmonary Resuscitation. However, once a pulse was noted it then took the ambulance crew approximately twenty-two minutes to leave the scene. She clearly felt that the time it took the crew to leave the premises was contributed to by the absence of a lift in the premises and to the extent that she felt at least half of the amount of time it took to leave the scene could have been avoided had a lift been in place. In reality Mr Stark had to be transported with some difficulty from his room, down some steps, and out to the ambulance and then taken to hospital. It could not be established from the evidence whether that increased amount of time contributed to Mr Stark’s eventual demise but I am concerned that a risk of future deaths may arise should someone requiring urgent medical attention be accommodated on the second floor of Newton House whose physical status is such that safe removal of that person from the building may be compromised and leave paramedics in similar difficulties. Although evidence was provided by the Nursing staff that when this gentleman was mobile he was able to use steps at the premises to get around, it appeared to me that there had been insufficient thought given to the prospect of him requiring urgent medical attention and whether his size may hinder his removal, particularly in the event of an emergency. ”
    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 Cygnet Newton House; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient assessment of residents’ size and emergency medical removal needs when allocating accommodation

    Wider context from the report

    “1. During the course of the Inquest I heard evidence from a Paramedic Reynolds who had been called to Regency House (now Newton House) which is a rehabilitation unit that cares for individuals with mental health issues, Mr Stark having previously been diagnosed as suffering from schizophrenia. He was an obese gentleman who weighed in excess of 30 stones, and he had been found unresponsive in his room. He was residing in a second floor room at the premises. The premises have no lift. The Paramedic indicated that after her arrival, there followed a period of time during which Mr Stark had no pulse and required Cardio Pulmonary Resuscitation. However, once a pulse was noted it then took the ambulance crew approximately twenty-two minutes to leave the scene. She clearly felt that the time it took the crew to leave the premises was contributed to by the absence of a lift in the premises and to the extent that she felt at least half of the amount of time it took to leave the scene could have been avoided had a lift been in place. In reality Mr Stark had to be transported with some difficulty from his room, down some steps, and out to the ambulance and then taken to hospital. It could not be established from the evidence whether that increased amount of time contributed to Mr Stark’s eventual demise but I am concerned that a risk of future deaths may arise should someone requiring urgent medical attention be accommodated on the second floor of Newton House whose physical status is such that safe removal of that person from the building may be compromised and leave paramedics in similar difficulties. Although evidence was provided by the Nursing staff that when this gentleman was mobile he was able to use steps at the premises to get around, it appeared to me that there had been insufficient thought given to the prospect of him requiring urgent medical attention and whether his size may hinder his removal, particularly in the event of an emergency. ”
    Open source report
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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