Concerns raised 2 Lack of additional staff training or guidance following incidents involving poorly managed resident conditions View source Lack of effective internal investigation and organisational learning from safeguarding incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Beatrice Smith · 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
Beatrice Smith, who was living at Riverside Court Care Home, developed seriously deteriorating leg and heel ulcers after 15 April 2025. Specialist attention was not sought and the ulcer was not always properly dressed; she developed sepsis, was admitted to hospital on 23 April 2025, and died that day. Concerns included the apparent absence of an effective internal investigation and of additional staff training or guidance, creating risks of missed learning and repeated inadequate care.
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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Lack of additional staff training or guidance following incidents involving poorly managed resident conditions
Wider context from the report “(1) A safeguarding referral was made in respect of Mrs Smith's condition at the time. Despite this, and despite Mrs Smith's death, no effective internal investigation appears to have been conducted. I am concerned that the absence of such an investigation means that opportunities for learning are likely to be overlooked. In turn this risks residents being exposed to repeated practices that are inadequate. This is a risk to those residents.
2) I asked the Manager of Riverside Court whether any additional training or guidance had been provided to staff in the light of this incident and Mrs Smith's death. She replied that it had not. Given my concerns that Mrs Smith's condition was not well managed I am concerned that the absence of such training and guidance risks a repeat of these events.
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Lack of effective internal investigation and organisational learning from safeguarding incidents
Wider context from the report “(1) A safeguarding referral was made in respect of Mrs Smith's condition at the time. Despite this, and despite Mrs Smith's death, no effective internal investigation appears to have been conducted. I am concerned that the absence of such an investigation means that opportunities for learning are likely to be overlooked. In turn this risks residents being exposed to repeated practices that are inadequate. This is a risk to those residents.
2) I asked the Manager of Riverside Court whether any additional training or guidance had been provided to staff in the light of this incident and Mrs Smith's death. She replied that it had not. Given my concerns that Mrs Smith's condition was not well managed I am concerned that the absence of such training and guidance risks a repeat of these events.
” 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 Complete Adults Safeguarding e-learning for all team members as refresher training.
Verbatim wording from the response “As part of the internal Serious Untoward Incident RCA an action plan and lessons learned identified key areas of learning. There has been ongoing refresher training to all team members to support their understanding of Safeguarding Adults. Aswell as the eLearning on our ‘Your Hippo’ Training Platform related to wounds and skin there has been, and further training attended and planned with the NHS Tissue Viability Team on wound care for all team members offering direct care.” Source location Response from Harbour Healthcare Limited
Open published response
×
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 Complete a Serious Untoward Incident root cause analysis with Human Resources support.
Verbatim wording from the response “Following the inquest a Serious Untoward Incident Root Cause Analysis was completed by Harbour Healthcare Head of Safeguarding with support from Human Resources.” Source location Response from Harbour Healthcare Limited
Open published response
×
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 Cascade Riverside Court’s inquest outcome and lessons learned across the company.
Verbatim wording from the response “15. Harbour Healthcare have introduced a Coroners Learning Forum in October 2025 where a team’s call is open to all interested individuals to share outcomes from Coroners Courts or potentially serious incidents along with any associated lessons learned for the wider organisation. The outcome of Riverside Courts inquest was cascaded to the company on Wednesday 3rd November 2025” Source location Response from Harbour Healthcare Limited
Open published response
×
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 Provide ongoing supervision and coaching for team development, supported by the Quality Team to assess effectiveness.
Verbatim wording from the response “The Quality Team support the home with Observational Support Visits which look at the quality-of-care planning and wound management. There is ongoing themed supervisions and coaching to key team members to support ongoing development.
When the nurses are completing their wound care training, they are completing reflective practice accounts to validate learning.” Source location Response from Harbour Healthcare Limited
Open published response
×
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 shared learning and updates through daily stand-up meetings and communication-improvement huddles.
Verbatim wording from the response “12. Shared learning and updates are reinforced through the Stand-Up Meetings each day in the Care Home along with Huddles for improvements in more effective communication.” Source location Response from Harbour Healthcare Limited
Open published response
×
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 Record actions in the Service Improvement Plan and share learning through Clinical Governance Meetings.
Verbatim wording from the response “11. When completing the home add any actions to their Service Improvement Plan and share learning through their Clinical Governance Meeting” Source location Response from Harbour Healthcare Limited
Open published response
×
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 Enroll all direct-care team members in further NHS wound-care training and development scheduled for early 2026.
Verbatim wording from the response “6. Riverside Court nurses have attended a wound care update by the local NHS trust and all team members who deliver care are signed up for further training and development through them early in 2026.” Source location Response from Harbour Healthcare Limited
Open published response
×
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 Provide wound-care training through the local NHS Tissue Viability Team, including an attended update for nurses.
Verbatim wording from the response “As part of the internal Serious Untoward Incident RCA an action plan and lessons learned identified key areas of learning. There has been ongoing refresher training to all team members to support their understanding of Safeguarding Adults. Aswell as the eLearning on our ‘Your Hippo’ Training Platform related to wounds and skin there has been, and further training attended and planned with the NHS Tissue Viability Team on wound care for all team members offering direct care.” Source location Response from Harbour Healthcare Limited
Open published response
×
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 Operate a monthly Coroners Learning Forum to share inquest and serious-incident outcomes and associated lessons across the organisation.
Verbatim wording from the response “As a company we have implemented a Coroners Lessons Learned forum which are held via teams every month. These commenced in October and offer a presentation of a coroners inquest relating to a home and then the associated lessons learned.” Source location Response from Harbour Healthcare Limited
Open published response
×
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 Operate a governance process and tracker for new Serious Untoward Incidents, reviewing root-cause findings, learning, actions and trends.
Verbatim wording from the response “10. There is a Governance Process in Place since June 2025 for all new Serious Untoward Incidents and we have a tracker monitored and reviewed by the Quality Team and Head of Safeguarding to look at detail in the RCA for lessons learned, actions, and trends in key areas” Source location Response from Harbour Healthcare Limited
Open published response
Concerns raised 1 Failure to investigate the care provided to residents following safeguarding concerns View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Peter Good · 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
Peter Good, a resident of Hilltop Hall Nursing Home, was admitted to hospital on 26 December 2023 with a blocked gastrostomy tube and was described on admission as being in poor condition, with concerns about his hygiene, wounds and oral care. He deteriorated despite antibiotic treatment and died on 9 January 2024 from pneumonia and complications associated with a previous cerebral infarction, Parkinson’s disease and skin ulceration. The principal concern was that Harbour Healthcare had not investigated how he was cared for at the nursing home, including potential ongoing risks to other residents and learning for staff and managers.
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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate the care provided to residents following safeguarding concerns
Wider context from the report “I am concerned in the light of this description that Harbour Healthcare as the owner and operator of Hilltop Hall has not instigated its own investigation into the way which Mr Good was cared for , with a view to considering any ongoing risk of harm to other residents and whether any learning can be derived for staff and managers of the home.
” 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 Complete a root cause analysis, full investigation and candid lessons learned for every death referred to the Coroner, with central monitoring.
Verbatim wording from the response “c) In all deaths that are referred to the coroner, Harbour Healthcare will complete a root cause analysis, a full investigation and complete a candid lessons learnt. This information has been shared across the company to promote best practice and mitigate risk. This information has been shared via a Bulletin to all home management teams, regional support teams and the Senior leadership team on the 19/2/25. This will be monitored by the Director of Strategic Risk, Safeguarding & Regulation.” Source location Response from Harbour Healthcare Ltd
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 The records indicate required care was delivered and do not support the description of Mr Good as dirty, unkempt, or neglected.
Verbatim wording from the response “A full investigation has been carried out into the Coroner’s concerns. This included taking statements from those present who denied that he left the home appearing dirty and unkempt.” Source location Response from Harbour Healthcare Ltd
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 An internal investigation was not considered usual without a specific reason, which was absent because the death was expected and notification was delayed.
Verbatim wording from the response “As Mr Good died in hospital, it would not be our usual practice to conduct an internal investigation unless there was reason to. We were not notified of the safeguarding referral until the Inquest. Furthermore, he was receiving End of Life care and his death was expected.” Source location Response from Harbour Healthcare Ltd
Open published response
Concerns raised 2 Failure to ensure that people with limited mobility have an easily reachable call bell when left in bed View source Lack of a checklist to confirm that residents’ required specific aids are in place View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
×
AI-generated summary
Susan Paley · 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
Susan Paley, a resident of Hilltop Court Nursing Home with complex neurological problems and very limited mobility, died after choking on food while eating in bed on 11 May 2024. Concerns included that she had been left without an easily reachable call bell and that care staff did not use a checklist to confirm residents had required aids in place.
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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure that people with limited mobility have an easily reachable call bell when left in bed
Wider context from the report “1. Given Ms Paley’s significant health problems and very limited mobility, it is a matter of concern that she had been left in bed without a call bell to hand which she could easily reach should she need to summon assistance ; and
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Lack of a checklist to confirm that residents’ required specific aids are in place
Wider context from the report “2. I am concerned that care staff at Hilltop Court do not currently have a checklist in use to accompany them when checking on residents which would act as an aide-memoire / confirmatory check that residents who require any specific aids (for instance bedrails, call-bell, sensor-mats etc.) have them in place as indicated .
” 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 Upgrade the call-bell system to support advanced infrared assistive technology.
Verbatim wording from the response “f Harbour Healthcare have currently upgraded the existing call bell system to enable the use of more advanced, infra-red assistive technology. This work has now been completed.” Source location Response from Harbour Healthcare
Open published response
×
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 call-bell and specific-aid procedures through documented staff supervisions and meetings.
Verbatim wording from the response “e The above measures are being regularly reinforced during documented supervisions and staff meetings.” Source location Response from Harbour Healthcare
Open published response
×
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 Assess residents’ requirements for specific aids before and on admission, then review those requirements monthly or after significant changes.
Verbatim wording from the response “a The assessment of the requirements for specific aids is completed pre-admission and again on admission, thereafter these requirements are reviewed monthly or in response to significant change in the resident’s condition.” Source location Response from Harbour Healthcare
Open published response
×
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 Translate call-bell and specific-aid requirements into care plans and time-specific handheld-device care actions reminding staff to provide and check them.
Verbatim wording from the response “b The outcome of the call bell risk assessment is then communicated into a care plan which details specific measures to ensure call bell devices, where in use, are working and within reach.” Source location Response from Harbour Healthcare
Open published response
×
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 Review and update residents’ call-bell risk assessments on admission, monthly, and after significant changes.
Verbatim wording from the response “a All residents have a call bell risk assessment in place. This is completed on admission and reviewed monthly thereafter or in response to significant changes in the resident’s condition. This was reviewed and updated in June 2024.” Source location Response from Harbour Healthcare
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 PCS care plans and planned care actions already provide the requested aide-memoire for residents’ required aids.
Verbatim wording from the response “a The assessment of the requirements for specific aids is completed pre-admission and again on admission, thereafter these requirements are reviewed monthly or in response to significant change in the resident’s condition.” Source location Response from Harbour Healthcare
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 call-bell assessments, care plans and planned actions are considered sufficient to ensure devices are functioning and within reach.
Verbatim wording from the response “a All residents have a call bell risk assessment in place. This is completed on admission and reviewed monthly thereafter or in response to significant changes in the resident’s condition. This was reviewed and updated in June 2024.” Source location Response from Harbour Healthcare
Open published response
Concerns raised 1 Failure to accurately identify the staff member and role responsible for resident care records View source
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
Joan Lunt · 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
Joan Lunt, who had idiopathic pulmonary fibrosis and lived in a nursing home, became seriously unwell on 26 October 2017 and died after being transferred to hospital; the inquest recorded natural causes. Concerns were raised about significant deficiencies in agency care staff’s recording of information on the nursing home’s electronic records system, including unclear staff identification, potential miscommunication, and effects on continuity of care. Evidence also indicated that the issue had apparently been raised previously but assurances that it had been addressed were not reflected in Mrs Lunt’s records.
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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately identify the staff member and role responsible for resident care records
Wider context from the report “In the course of evidence heard at the inquest, it emerged that there were significant deficiencies in the way in which agency care staff recorded information about residents on Hilltop Hall’s electronic records system .
The evidence before the court was that agency staff would either:
1. Relay matters to be recorded in the notes to a substantive member of staff who would then make an entry reflecting what they had been told (i.e. in the name of the substantive staff member in question) ; or
2. Make an entry directly on the system which simply records it has been made by ‘Agency Staff’, rather than explaining the identity and role of the person making the record.
This issue raises significant concerns about the integrity of Hilltop’s electronic patient record, particularly as far as it relates to checks made on vulnerable residents by care staff. In addition to making it difficult or impossible in retrospect to identify which member of staff has undertaken what activity , the current system has the potential to lead to miscommunication between staff members (for example, in relation to which staff member on a shift has undertaken important checks on residents’ wellbeing), and can be detrimental to continuity of care.
A further matter of concern which emerged in evidence from the Team Manager from Stockport Metropolitan Borough Council’s Adult Safeguarding service is that this issue has apparently been raised previously by the local authority in the context of another safeguarding investigation. The Team Manager’s evidence was that assurances had been received from managers at Hilltop Hall that this issue had been addressed, whereas Mrs Lunt’s records suggest this is not, in fact, the case.
” Open source report
3 Apr 2018 Barbara Haley · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 2 Provision of food unsuitable for a soft diet View source Failure to supervise high-risk residents while eating View source
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
Barbara Haley · 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
Barbara Haley inhaled vomit, saliva, food or liquid while resident at Hilltop Court Care Home, developed a chest infection, and died at Stepping Hill Hospital on 13 October 2017 after suffering a cardiac arrest en route. Concerns included her being provided food unsuitable for her soft diet and being left alone to eat despite having been assessed as at high risk of choking.
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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Provision of food unsuitable for a soft diet
Wider context from the report “1. Mrs Haley was on a soft diet (described as a “fork-mashable diet” in evidence). Despite this, there was evidence that Mrs Haley had been provided with food items not suitable for her by staff . In particular, on one occasion toast was found in her room . On another occasion, staff had apparently suggested to a family member that chocolate could be given to Mrs Haley .
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise high-risk residents while eating
Wider context from the report “2. During the course of her evidence, ████████ (Home Manager) explained that Mrs Haley was assessed as being at High Risk of choking and scored high on the risk assessment that had been carried out. Despite this, Mrs Haley would be left alone in her room to eat because ████████ stated she did not like to have staff present when she was eating; she would then refuse to eat. We heard evidence from a manager at another home that Mrs Haley would eat when she was in the dining room with other residents, where staff could also observe her. It was of concern that Mrs Haley was being left alone in her room to eat when she had been assessed as being at the high risk of choking .
” Open source report
31 Jul 2017 Michael Bingham · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 4 Lack of clarity and consistency in head and neck injury guidelines for considering CT scans in older people with dementia or cognitive impairment View source Lack of consistent regulatory or guidance requirements for assessing fall risks from emergency door release panels View source Failure to provide alarms indicating when internal secure doors become insecure across the service View source Inadequate inspection procedures for Registered Persons’ compliance with internal secure door safety and security requirements View source See 1 more concern
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
Michael Bingham · 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
Michael Bingham fell down stairs at Hilltop Court Care Home on 22 September 2016 after an emergency door release caused internal secure doors to open. He sustained C1/C2 fractures, was not diagnosed with a CT scan, later developed aspiration pneumonia, and died on 24 September 2016; concerns included door security alarms, guidance and inspection procedures, clarity about CT scans for older people with cognitive impairment, and the resulting risk of further deaths.
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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Lack of clarity and consistency in head and neck injury guidelines for considering CT scans in older people with dementia or cognitive impairment
Wider context from the report “I am concerned that the current Guidelines for Head/neck injuries (as amended) may continue to provide a lack of clarity as to when CT scans should be considered in those over 65 and with dementia or other cognitive impairment . The word ‘confusion’ remains under the general guidance (bullet point 5) but has been changed to ‘dementia’ under the guidance for those who are already being subject to a head scan . I ask that you consider reviewing your guidelines to ensure clarity and consistency of their clinical application.
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent regulatory or guidance requirements for assessing fall risks from emergency door release panels
Wider context from the report “I accept that on the present Regulations it is for the Registered Person to make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, I ask you to review, in light of the evidence I have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due to falls posed by the use of an emergency door release panel . I also ask you to review your inspection procedures in respect of a Registered Person’s compliance with the Regulations in respect of the safety and security of internal secure doors.
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to provide alarms indicating when internal secure doors become insecure across the service
Wider context from the report “It was accepted by you during the inquest that there was a ‘blind spot’ in the risk assessment of the internal secure doors , in that you were not required by any regulatory body to have an alarm to alert staff when secure doors became insecure by virtue of the use of the green emergency door release or otherwise.
I accept that you have now implemented an alarm system in Hilltop Court Care home that will indicate when the internal doors become insecure and have fitted auditory alarms in relation to the external doors. You indicated that you are in the process of implementing similar systems in the other care homes owned by Harbour Healthcare. I am concerned that without the implementation of these alarms across your service provision there would continue to be circumstances that create a risk of other deaths . I would be grateful for an indication of when you expect this implementation to be completed by way of response.
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Inadequate inspection procedures for Registered Persons’ compliance with internal secure door safety and security requirements
Wider context from the report “I accept that on the present Regulations it is for the Registered Person to make a risk assessment in relation to internal secure doors and the safety and security that they provide to service users. However, I ask you to review, in light of the evidence I have received in the course of this investigation whether there should be a further issue of regulations or guidance to ensure a consistent approach in respect of the assessment of any safety risk due to falls posed by the use of an emergency door release panel. I also ask you to review your inspection procedures in respect of a Registered Person’s compliance with the Regulations in respect of the safety and security of internal secure doors .
” Open source report
30 Jul 2014 Edna Smither · Prevention of Future Deaths report Manchester South
View report summary
Concerns raised 5 Lack of training for calm leadership during emergencies View source Failure to designate clear emergency leadership View source Lack of up-to-date first aid certification and choking-response knowledge among staff View source Locked access door delaying emergency transfer View source Failure to report reportable incidents promptly under RIDDOR View source See 2 more concerns
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
Edna Smither · 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
Edna Smither choked on sausage while being fed lunch at Peel Moat Care Home on 25 April 2013 and died later that day in hospital. Concerns included limited up-to-date first-aid certification, a delay caused by a locked door, panic and a lack of calm leadership or training, and failures to report incidents under RIDDOR without delay.
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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Lack of training for calm leadership during emergencies
Wider context from the report “3. All the staff in attendance, by their own admission, were in a state of panic. No-one, including the senior staff took a position of calm leadership and there seemed to be no training for this nor a recognition as to who really was in charge.
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to designate clear emergency leadership
Wider context from the report “3. All the staff in attendance, by their own admission, were in a state of panic. No-one, including the senior staff took a position of calm leadership and there seemed to be no training for this nor a recognition as to who really was in charge .
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Lack of up-to-date first aid certification and choking-response knowledge among staff
Wider context from the report “1. It transpired during the course of the hearing that only one (comparatively junior) member of staff present on the day of the incident and death, had a First Aid certificate which was ‘in date’ . Whilst I recognise that there is no legal requirement for this, none the less I feel it would be very helpful for all staff to have up-to-date certification, so that they would know when to, and how to, carry out abdominal thrusts to dislodge food boluses etc.
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Locked access door delaying emergency transfer
Wider context from the report “2. There was a door which Mrs Smither was to be carried through by the ambulance staff, and this door was locked . A delay occurred whilst this was unlocked . Was this door in fact a fire escape door, and if so has the situation now been changed?
” 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 Harbour Healthcare Ltd.; that does not assign responsibility.
PFD Monitor interpretation Failure to report reportable incidents promptly under RIDDOR
Wider context from the report “4. There were two failures to report incidents under RIDDOR . Mrs Smither was involved in an incident concerning the use of a hoist, and she was injured. It apparently took the then owners 11 months to report that incident to the Environmental Health Dept. On the occasion of the choking which led to her death, again it took over a week for this to be reported . The guidance document entitled “RIDDOR Explained” does say where there is a death or major injury, it must be reported without delay (e.g. by telephone) and a completed accident report form must follow within ten days.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations