Frome Care Village

Private and voluntary organisations · Residential care home

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First report 7 Nov 2023•Latest report 7 Nov 2023

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

Statements from Frome Care Village linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to Frome Care Village (Alexis Care Limited), now represented here by Frome Care Village.

    Somerset

    AI-generated summary

    Irene Joy White · 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

    Irene Joy White, who had dementia and became immobile after a fall and hip-fracture surgery, was discharged to a nursing home without further thromboprophylaxis and was not mobilised beyond regular repositioning. She died of a pulmonary embolism, and concerns were raised about the nursing home's failure to identify and manage her DVT risk, including the absence of a DVT policy.

    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 Frome Care Village; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide TED stockings or similar thromboprophylactic equipment

    Wider context from the report

    “I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
    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 Frome Care Village; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to learn from and reflect on DVT-related care to change practice

    Wider context from the report

    “I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
    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 Frome Care Village; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of an active DVT policy

    Wider context from the report

    “I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
    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 Frome Care Village; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain and clarify discharging-hospital information about care needs and thromboprophylaxis

    Wider context from the report

    “I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
    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 Frome Care Village; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of joined-up clinical leadership and coordination between management and clinical teams

    Wider context from the report

    “I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
    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 Frome Care Village; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to mobilise immobile residents to minimise DVT risk

    Wider context from the report

    “I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
    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 Frome Care Village; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify and minimise residents’ DVT risk

    Wider context from the report

    “I am concerned following the evidence presented to the Inquest that: (i) Frome Nursing Home employs clinically trained staff who would have been well aware (or should have been well aware) of the risk of developing DVT in an immobile patient and yet: (a) Did not make any enquiries with the discharging hospital as to her care needs and lack of thromboprophylaxis. Despite appropriate medical/clinical knowledge the Home did not question this and/or take any active steps whatsoever to ascertain Mrs White’s needs or treatment plan; (b) Did not take any steps to acquire any TED stockings, or similar, to minimise the risk of a DVT; (c) Did not take any steps to mobilise Mrs White, over and above repositioning her in bed every four hours, to minimise the risk of a DVT (ii) Frome Nursing Home did not have a DVT Policy in place at the time of Mrs White’s death, and no such active policy was in place at the time of the Inquest and so I am concerned that there has been no active learning and/or meaningful reflection since Mrs White’s death; meaning that practices have not changed and vulnerable residents remain at risk. I am concerned that the Home did not take appropriate and reasonable steps to identify her risk and then take such steps to minimise it. The overwhelming thrust of the evidence presented indicated a poor attitude to a joined-up and cohesive response from the management and clinical teams and this resulted in a lack of clinical leadership, judgment and action being taken. Mrs White lacked capacity due to her cognitive impairment and so was unable to appreciate the risks that immobility posed to her. She was entirely reliant (because of age, cognitive impairment and general infirmity) on the Home to anticipate her risks and needs in this regard. ”
    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

Data last updated 7 September 2026