Recipient

Hart Care Residential Home

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First report 26 Mar 2021•Latest report 26 Mar 2021

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. 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 Hart Care Residential Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to “Hart Care Nursing and Residential Home”, a former name of Hart Care Residential Home.

    Plymouth, Torbay and South Devon

    AI-generated summary

    Clara Ellen Freeman · 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

    Clara Ellen Freeman suffered an unwitnessed fall at a care home and remained immobilised on the floor for approximately four hours while awaiting an ambulance. She later died in hospital after developing medical complications. The principal concerns related to staff proficiency in caring for her after the fall and communicating relevant information, including changes in her condition, to the ambulance service.

    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 Hart Care Residential Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to accurately record medical information including vital signs

    Wider context from the report

    “(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition. It is requested that the training for care and nursing staff be reviewed to consider; a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency b) Accurate recording of medical information including vital signs c) Awareness of the risks of medical complications following falls and long lies. ”
    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 Hart Care Residential Home; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of care and nursing staff awareness of the risks of medical complications following falls and long lies

    Wider context from the report

    “(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition. It is requested that the training for care and nursing staff be reviewed to consider; a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency b) Accurate recording of medical information including vital signs c) Awareness of the risks of medical complications following falls and long lies. ”
    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 Hart Care Residential Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of care and nursing staff to communicate relevant information and changes in condition effectively to ambulance and other medical service providers after an accident or medical emergency

    Wider context from the report

    “(1) Evidence was heard regarding the level of proficiency of the care and nursing staff in dealing with the care of the Deceased after her fall and the interaction of staff with the ambulance service control centre call handlers, particularly in the passing of relevant information and any changes in the Deceased's condition. It is requested that the training for care and nursing staff be reviewed to consider; a) Effective interaction with the ambulance service and other medical service providers after an accident or medical emergency b) Accurate recording of medical information including vital signs c) Awareness of the risks of medical complications following falls and long lies. ”
    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