Hawthorn Green Residential and Nursing Home

Private and voluntary organisations · Nursing home

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First report 16 Oct 2015•Latest report 16 Oct 2015

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 Hawthorn Green Residential and Nursing Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    John William BIRD · 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

    John William Bird, aged 92, fell at his care home on the evening of 29 April 2014 and later died from the injury sustained. The principal concerns were that the falls risk assessment was not available at the inquest and that the carer who found him appeared unfamiliar with his risk assessment and care plan, despite Mr Bird being assessed as at very high risk of falls.

    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 Hawthorn Green Residential and Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to make falls risk assessment records available for review

    Wider context from the report

    “You were unable to detail in court the entirety of the falls risk assessment you had undertaken for Mr Bird, because you did not bring the record of the risk assessment to the inquest, despite the nature of Mr Bird’s death and a written request from my coroner’s officer. However, you were confident that you had assessed Mr Bird as being at very high risk of falls, as a consequence of his level of cognitive impairment coupled with his ability to walk without assistance. (This is, of course, a very difficult combination.) Yet the carer who found Mr Bird after his fall, did not appear to have any familiarity with risk assessments. Even allowing for possible language difficulties (the carer is not a native English speaker), he assessed Mr Bird’s ability to mobilise unaided as “fine”, and did not see any particular risks for him. When I put the carer’s evidence to you in court, you told me that he should know about the risk assessments. You later agreed in evidence that, as manager of the care home, it is your responsibility to ensure that all staff are familiar with risk assessments and the resulting care plan for each resident. ”
    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 Hawthorn Green Residential and Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure staff familiarity with residents’ risk assessments and resulting care plans

    Wider context from the report

    “You were unable to detail in court the entirety of the falls risk assessment you had undertaken for Mr Bird, because you did not bring the record of the risk assessment to the inquest, despite the nature of Mr Bird’s death and a written request from my coroner’s officer. However, you were confident that you had assessed Mr Bird as being at very high risk of falls, as a consequence of his level of cognitive impairment coupled with his ability to walk without assistance. (This is, of course, a very difficult combination.) Yet the carer who found Mr Bird after his fall, did not appear to have any familiarity with risk assessments. Even allowing for possible language difficulties (the carer is not a native English speaker), he assessed Mr Bird’s ability to mobilise unaided as “fine”, and did not see any particular risks for him. When I put the carer’s evidence to you in court, you told me that he should know about the risk assessments. You later agreed in evidence that, as manager of the care home, it is your responsibility to ensure that all staff are familiar with risk assessments and the resulting care plan for each resident. ”
    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