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First report 14 Oct 2021•Latest report 14 Oct 2021

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

  1. Nottinghamshire

    AI-generated summary

    Mr Murray Hyslop · 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 Murray Hyslop developed Covid-19, reduced fluid intake and appetite, and became dehydrated, malnourished and affected by acute kidney injury. He was admitted to hospital on 24 December 2020 but did not recover and died from natural disease on 16 January 2021. Concerns included inadequate prevention of pressure damage, failure to identify when he needed medical attention, and a lack of openness about learning from adverse events.

    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 GP; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of senior staff to openly consider and learn from adverse care events

    Wider context from the report

    “(3) Learning from adverse events – the culture within senior staff of obfuscation and denial when issues regarding care are raised was of significant concern to me as it is hard to have confidence that, as they said to me, “lessons will be learned”. It was appropriate for the senior management to be supportive of their frontline staff who, as set out above, worked hard when the care home was understaffed. They were not, however, open minded to consider areas where significant changes in practice and culture needed to take place. ”
    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 GP; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of expectation for staff to take a broader view when identifying residents in need of medical attention

    Wider context from the report

    “(2) Identifying a resident in need of medical attention – some of the difficulties in Mr Hyslop’s care were exacerbated by the outbreak of Covid-19, but there was no evidence of any expectation upon any members of staff to consider a broader view of Mr Hyslop’s presentation than how he was on a particular day. The witnesses did not seek to suggest that they usually did this but were unable to during the outbreak and so I consider that it is likely that this was an issue was existed both before and after the outbreak. I was more reassured in this area by “Restore 2” materials and training which provide very clear and helpful guidance to carers. It is not clear to me how this training, which has been completed by the registered manager, has been effectively cascaded to frontline care staff and their evidence to me suggested that this has not happened to date; ”
    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 GP; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide sufficiently responsive review of pressure-damage prevention needs

    Wider context from the report

    “(1) Prevention of pressure damage – there was a lack of appreciation of the need to consider Mr Hyslop’s extreme vulnerability to pressure damage when he was very unwell, dehydrated, malnourished and largely immobile. Policies and practices supported only monthly review of his needs and that is insufficiently responsive in order to appropriately prevent damage from occurring; ”
    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 GP; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to effectively cascade medical-assessment training to frontline care staff

    Wider context from the report

    “(2) Identifying a resident in need of medical attention – some of the difficulties in Mr Hyslop’s care were exacerbated by the outbreak of Covid-19, but there was no evidence of any expectation upon any members of staff to consider a broader view of Mr Hyslop’s presentation than how he was on a particular day. The witnesses did not seek to suggest that they usually did this but were unable to during the outbreak and so I consider that it is likely that this was an issue was existed both before and after the outbreak. I was more reassured in this area by “Restore 2” materials and training which provide very clear and helpful guidance to carers. It is not clear to me how this training, which has been completed by the registered manager, has been effectively cascaded to frontline care staff and their evidence to me suggested that this has not happened to date; ”
    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