Haddon Court Limited

Private and voluntary organisations · Residential care home

Pin Request correction

First report 10 May 2024•Latest report 10 May 2024

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
100%

Found for named reports

Concerns addressed
1

Across all linked responses

Stated actions
1

Described in responses

Concerns and recipient responses

Statements from Haddon Court Limited 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

    Mr Terence John Manning · 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 Terence John Manning, a resident of Haddon Court Rest Home, experienced a choking incident while eating a meal on 22 October 2023 and died in hospital on 24 October 2023. The concerns included inaccurate care records caused by carers carrying forward records from other residents, meaning the records did not reflect the food being given to him, and the absence of a Speech and Language Therapy referral despite a known propensity to eat quickly.

    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 Haddon Court Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate resident-specific care and dietary records

    Wider context from the report

    “Mr Terence John Manning was a resident at Haddon Court from 29 June 2023. It was known to Haddon Court Rest Home, that Mr Manning had a propensity to eat quickly and to take food from other plates. Mr Manning was not being fed a pureed or soft texture diet, and entries to this effect in the care records are errors in the record keeping. These errors had been caused by carers carrying forward the details of records relating to other residents from entries made on the records of those other residents. It was noted in the evidence, that erroneous record keeping had taken place over a period of time and involved multiple carers. It was caused by carers transposing the records of one resident into the care records of another, leading to inaccuracies. I found that these matters gave rise to a risk of future death as the record keeping was inaccurate and did not reflect the foods being given to Mr Manning, and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. ”
    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 Haddon Court Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide a pureed or soft texture diet

    Wider context from the report

    “Mr Terence John Manning was a resident at Haddon Court from 29 June 2023. It was known to Haddon Court Rest Home, that Mr Manning had a propensity to eat quickly and to take food from other plates. Mr Manning was not being fed a pureed or soft texture diet, and entries to this effect in the care records are errors in the record keeping. These errors had been caused by carers carrying forward the details of records relating to other residents from entries made on the records of those other residents. It was noted in the evidence, that erroneous record keeping had taken place over a period of time and involved multiple carers. It was caused by carers transposing the records of one resident into the care records of another, leading to inaccuracies. I found that these matters gave rise to a risk of future death as the record keeping was inaccurate and did not reflect the foods being given to Mr Manning, and engaged my duty under paragraph 7, Schedule 5, of the Coroners and Justice Act 2009 and regulations 28 and 29 of the Coroners (Investigations) Regulations 2013. ”
    Open source report

    Source evidence

    How this respondent action was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Reinforce accurate record-keeping and require staff to check records after using the software’s repeat functionality.

    Verbatim wording from the response

    “In terms of our staff, we would like to reassure you that all staff have been reminded about the importance of accuracy in record keeping. We have particularly reminded the staff about the risks of using what is termed the “repeat functionality” of the software in question, and to ensure that records are checked for accuracy after use of this feature.”

    Source location

    Response from Haddon Court Rest Home
    Page 1 · response
    Published 17 September 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Further software changes cannot be undertaken directly; the matter has been raised with and can only be influenced through the provider.

    Verbatim wording from the response

    “It is important that carers are encouraged to record the most accurate and person-centred records as possible. Based on your input, we will review the repeat functionality in detail and consider certain categories of care to be removed from the repeat functionality. That would force users to individually report the details for each resident in those selected categories.”

    Source location

    Response from Haddon Court Rest Home
    Page 2 · response
    Published 17 September 2024

    Open published response

    Source evidence

    How this respondent position was interpreted

    PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

    PFD Monitor interpretation

    Existing staff reminders, record-checking practices and other measures are considered robust enough to ensure accurate care records.

    Verbatim wording from the response

    “In terms of our staff, we would like to reassure you that all staff have been reminded about the importance of accuracy in record keeping. We have particularly reminded the staff about the risks of using what is termed the “repeat functionality” of the software in question, and to ensure that records are checked for accuracy after use of this feature.”

    Source location

    Response from Haddon Court Rest Home
    Page 1 · response
    Published 17 September 2024

    Open published response
Back to top

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