13 Feb 2024 Blanche Audrey Knowles · Prevention of Future Deaths report West Yorkshire (Eastern)
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Concerns raised 1 Failure to adequately convey and proactively flag the importance of cooling burns by running water to nursing staff 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.
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AI-generated summary
Blanche Audrey Knowles · 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
Blanche Audrey Knowles, who had multiple health conditions and was receiving nursing care, suffered burns when an inadequately checked hot drink spilled into her lap. She later became frail and died on 1 September 2023; the burns contributed to her death. The principal concern was that staff had not been adequately informed or trained about cooling burns under running water.
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× 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately convey and proactively flag the importance of cooling burns by running water to nursing staff
Wider context from the report “Whilst it was clear from the written and oral evidence provided to the inquest that measures had been implemented to address the risks from hot drinks, for example by the purchase and use of thermometers, upon questioning, the matter of the importance of assisting an individual who has suffered burns by way of ‘cooling by running water’ as noted by the Ambulance staff did not appear to have been adequately conveyed to staff , be that through training or by way of clear communication as operational matters/requirements in the nursing care context.
The burns suffered by Blanche contributed to the cause of her death and whilst it was not established that the recorded failure to apply ‘cooling by running water’ to her injuries would have made a material difference, I remain concerned that the clear importance of applying ‘cooling by running water’ does not appear to be proactively flagged in relevant policies/procedures or by active practical/operational communications to staff .
” Open source report
11 Jul 2019 Robert Charles Rostron · Prevention of Future Deaths report Manchester West
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Concerns raised 5 Absence of another qualified nurse when an agency nurse is on duty View source Medication administration by agency nurses unfamiliar with the unit View source Reliance on nursing qualifications and agencies to establish agency nurses' ability, suitability and training View source Use of agency nurses as senior staff in charge of shifts View source Lack of formal induction and orientation for agency nurses View source See 2 more concerns
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Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Robert Charles Rostron · 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
Robert Charles Rostron, who had Type 1 diabetes and Alzheimer’s disease, became unconscious after an agency nurse administered insulin despite recording a low blood sugar reading of 2.2. He did not recover to his previous baseline and later died in hospital; the inquest found that the insulin administration exacerbated his natural illness. Concerns included the use of agency nurses without formal induction, insufficient knowledge of records and care plans, and an agency nurse being the only qualified nurse in charge of the unit.
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× 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Absence of another qualified nurse when an agency nurse is on duty
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Medication administration by agency nurses unfamiliar with the unit
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Reliance on nursing qualifications and agencies to establish agency nurses' ability, suitability and training
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse . I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Use of agency nurses as senior staff in charge of shifts
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift . I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of formal induction and orientation for agency nurses
Wider context from the report “I am concerned by the use of Agency Nurses in the homes under the management of HC One. In particular, I am concerned by the lack of formal induction and orientation to the unit on this occasion. I am concerned that reliance is placed upon the nursing qualification itself and the agency providing the nurse. I am concerned that an Agency Nurse was used as the senior member of staff in charge of the shift. I am concerned that the Agency Nurse was giving out medication when he had never worked at the Unit before and. I am concerned that there were no other qualified nurses on the Spring Unit at the time.
” Open source report
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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 Store agency profiles with completed orientation booklets in Cornerstone and allow agency workers to retain booklet copies.
Verbatim wording from the response “The agency profiles already in operation and expected standard practice in all our homes, will be required to be held alongside the completed orientation booklet and held within the quality assurance system, Cornerstone. We have developed the system to allow the agency worker to also retain a copy of their booklet.” Source location 2019-0237-Response-by-The-Kind-Care-Company
Open published response
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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 Revise the implemented agency procedure to strengthen checks on agency suppliers.
Verbatim wording from the response “Since 2016, we have developed and implemented an agency procedure and although this was not due for a review until next year, a revision is in train to revise and this has already resulted in improvements in ensuring robust checks to agencies. I have attached (Appendix 4) the current version, not in place at the time of the incident, and will be happy to supply the updated version when finalised.” Source location 2019-0237-Response-by-The-Kind-Care-Company
Open published response
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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 Orient agency nurses to risk assessments, care plans, diabetes resources, hypoglycaemia materials, medicines, and relevant policies through senior home staff.
Verbatim wording from the response “As part of the agency nurse’s orientation to the home, the location of all risk assessments, care plans, the diabetes resource file, physical posters regarding hypo/hyperglycaemia management, hypo box, medicines and policies and procedures would be shown, as mentioned previously, to them by the most senior member of staff at the home, to support them in their shift, which would be the Home Manager, Deputy Home Manager or Nurse in charge of the home. This ensures that any agency nurse is fully orientated and knows where to locate important documents as well as summoning support within the home.” Source location 2019-0237-Response-by-The-Kind-Care-Company
Open published response
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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 Require agency nurses to submit insulin-training records, audit qualifications annually, and suspend non-compliant agencies.
Verbatim wording from the response “The procedure now adopted after close liaison with agency suppliers is that all agency nurses who wish to work in HC-One homes are required to complete and submit a record of training, which specifically stipulates whether they have the skills, knowledge and up to date training to administer insulin safely. These training records and qualifications are audited annually and we can and do suspend use of agencies if there is any discrepancy or failure to complete. We currently have three agencies suspended for failing to comply in part with this agreement.” Source location 2019-0237-Response-by-The-Kind-Care-Company
Open published response
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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 Block-book agency staff where possible to improve familiarity with home standards and residents’ needs.
Verbatim wording from the response “There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.” Source location 2019-0237-Response-by-The-Kind-Care-Company
Open published response
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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 and distribute a strengthened agency-staff orientation booklet across the company.
Verbatim wording from the response “There are still unfortunately occasions when we are required to call upon the need to cover nursing shifts at this and other homes with agency nurses. However, we have implemented a series of additional measures to reduce the likelihood of an agency nurse being required to lead a shift without having worked at the home or individual House before.” Source location 2019-0237-Response-by-The-Kind-Care-Company
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 HC-One does not rely solely on nursing qualifications; it verifies agency nurses’ training, skills and qualifications for safe insulin administration.
Verbatim wording from the response “The procedure now adopted after close liaison with agency suppliers is that all agency nurses who wish to work in HC-One homes are required to complete and submit a record of training, which specifically stipulates whether they have the skills, knowledge and up to date training to administer insulin safely. These training records and qualifications are audited annually and we can and do suspend use of agencies if there is any discrepancy or failure to complete. We currently have three agencies suspended for failing to comply in part with this agreement.” Source location 2019-0237-Response-by-The-Kind-Care-Company
Open published response
18 Apr 2019 Mrs Margaret Melia · Prevention of Future Deaths report Black Country
View report summary
Concerns raised 1 Inadequate discharge and pre-assessment process for subcutaneous fluid requirements View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mrs Margaret Melia · 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
Mrs Margaret Melia was admitted to Dovetail Court Care Home in October 2018, later developed declining food and fluid intake, was admitted to hospital with dehydration and a lower respiratory tract infection, and died on 7 November 2018 while receiving end-of-life palliative care. The inquest identified an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home concerning the requirement for subcutaneous fluids.
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× 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate discharge and pre-assessment process for subcutaneous fluid requirements
Wider context from the report “1. Evidence emerged during the inquest that there was an inadequate discharge and pre-assessment process between Lakeview Care Home and Dovetail Care Home over the requirement of subcutaneous fluids .
” Open source report
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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 organisational pre-admission and admission policies and practices.
Verbatim wording from the response “We reviewed our policies and practices as an organisation in relation to our pre-admission and admission processes.” Source location 2019-0320-Response-by-HC-One
Open published response
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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 Include guidance requiring further information when pre-admission assessment occurred more than five days before admission, including medication and healthcare review updates.
Verbatim wording from the response “On reviewing our practices, we identified that if a delay occurred between the pre-admission assessment conducted, there needed to be clearer guidance set out for colleagues within our Admission, Transfer and Discharge Procedure (Appendix 1). We have now included practice that in the eventuality the pre-assessment was completed more than five days prior to admission to the home, further information should be sought from the hospital ward/care home/social worker as soon as possible. This will include the update of any medication changes or outcome of any recent healthcare professional reviews of the person during this period, to avoid any misunderstanding that could result in harm.” Source location 2019-0320-Response-by-HC-One
Open published response
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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 the current admission process checklist.
Verbatim wording from the response “We reviewed the current Admission process checklist.” Source location 2019-0320-Response-by-HC-One
Open published response
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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 the revised admission practice across homes through the Homes’ Bulletin.
Verbatim wording from the response “The changes to practice have been cascaded across the organisation via our Homes’ Bulletin, which is sent to our homes.” Source location 2019-0320-Response-by-HC-One
Open published response
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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 Update the admission process checklist across all homes to reflect the revised practice.
Verbatim wording from the response “Our Admission process checklist (Appendix 2), which is available within all our homes to ensure all aspects of the organisation’s pre-admission and admission processes are completed, has been updated to reflect this improvement in practice.” Source location 2019-0320-Response-by-HC-One
Open published response
Concerns raised 9 Lack of care plans addressing identified high fall risk View source Failure to refer wheelchair suitability to wheelchair services View source Failure to report multiple falls to the care commissioner View source Failure to record refusal to follow safety directions View source Failure to refer mobility for occupational therapy review View source Failure to encourage wheelchair seatbelt use after falls View source Failure to investigate subsequent falls View source Failure to encourage compliance with wheelchair-fall prevention measures View source Failure to plan measures to prevent wheelchair falls View source See 6 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Mr Frederick Raymond BROOKER · 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 Frederick Raymond Brooker, who used a wheelchair in a residential care home, sustained multiple falls, including a fall on 10 July 2018 that caused a catastrophic traumatic bleed and from which he died on 14 July 2018. The principal concerns were that, despite his recognised high risk of falling, the care home did not put adequate care plans or other measures in place, review the wheelchair or involve relevant services, investigate subsequent falls, or provide evidence of encouragement to use the wheelchair seatbelt.
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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of care plans addressing identified high fall risk
Wider context from the report “(1) Despite Mr Brooker sustaining multiple falls of increasing severity, no reasonable measures were taken by the Care Home staff to address the high risk of falling. Risk assessments were completed. The high risk was recognised, but there were no care plans to address the identified risk .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to refer wheelchair suitability to wheelchair services
Wider context from the report “(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him . There was no referral to occupational therapy for a review of Mr Brooker’s mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to report multiple falls to the care commissioner
Wider context from the report “(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker’s mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record refusal to follow safety directions
Wider context from the report “(4) There was reliance on the fact that Mr Brooker had mental capacity. This should not override the importance of care planning. Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded . Following the falls, there was no evidence of a care plan to reduce the risk of falling from the wheelchair – or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe. The only record of Mr Brooker declining to use the wheelchair seatbelt, was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to refer mobility for occupational therapy review
Wider context from the report “(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker’s mobility . Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to encourage wheelchair seatbelt use after falls
Wider context from the report “(2) There were no steps taken by the Care Home staff to report the multiple falls to the London Borough of Redbridge who were commissioning Mr Brooker’s care. There was no referral to wheelchair services to consider whether the wheelchair provided for Mr Brooker was appropriate for him. There was no referral to occupational therapy for a review of Mr Brooker’s mobility. Following the falls, there was no evidence of Mr Brooker being encouraged to use his seat belt .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate subsequent falls
Wider context from the report “(3) An investigation took place into a fall on the 15th March 2018. No further investigations were carried out by the home into the subsequent falls, including those falls resulting in injury . Senior staff were not, therefore, always aware of the circumstances of each fall. They were therefore not able to identify the optimum means of attempting to reduce the risk of further falls.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to encourage compliance with wheelchair-fall prevention measures
Wider context from the report “(4) There was reliance on the fact that Mr Brooker had mental capacity. This should not override the importance of care planning. Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence of a care plan to reduce the risk of falling from the wheelchair – or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe. The only record of Mr Brooker declining to use the wheelchair seatbelt, was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to plan measures to prevent wheelchair falls
Wider context from the report “(4) There was reliance on the fact that Mr Brooker had mental capacity. This should not override the importance of care planning. Attempts should have been made to plan care to keep Mr Brooker safe. He should have been encouraged to follow the care plan and if he declined, this should have been clearly recorded. Following the falls, there was no evidence of a care plan to reduce the risk of falling from the wheelchair – or evidence of Mr Brooker being encouraged to comply with directions to help to keep him safe. The only record of Mr Brooker declining to use the wheelchair seatbelt, was on the admission assessment (26.1.18). There was no evidence of encouragement after he began to fall from the wheelchair.
” Open source report
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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 Implement organisation-wide multifactorial falls risk assessments, including reassessment, care planning, documentation and review requirements.
Verbatim wording from the response “a. Multi-factorial Risk Assessments” Source location 2019-0097-Response-by-HC-One
Open published response
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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 Develop and provide a post-fall protocol flow chart and checklist to guide staff through required actions, documentation and investigation.
Verbatim wording from the response “A Post Fall Protocol Flow Chart [Exhibit 3] is available and provides useful at-a-glance guidance for staff. To remind them of the steps to follow after a fall. In order to ensure compliance with the process, a checklist has been developed to provide prompts to the care home team on documentation and process [Exhibit 4] and to ensure that our staff teams are actively thinking about each of the actions required after a fall.” Source location 2019-0097-Response-by-HC-One
Open published response
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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 Falls among older people cannot always be prevented, although risks can be minimised and staff responses improved.
Verbatim wording from the response “Regrettably, it is not uncommon for older people to experience a fall, for a variety of reasons. Such falls cannot always be prevented but as an organisation we are committed to supporting people to maintain their safety wherever possible and to ensure that our Colleagues respond appropriately in the event that a fall does occur.” Source location 2019-0097-Response-by-HC-One
Open published response
Concerns raised 4 Risk of Falls Assessment Tool failing to provide clear and consistent guidance View source Failure to investigate repeated falls View source Lack of clear written requirements for communal-area supervision View source Failure to supervise vulnerable residents in communal areas 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
Mrs Doris Douthwaite · 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
Mrs Doris Douthwaite, who had vascular dementia and other complex medical conditions, suffered three falls at Greatwood House Residential Care Home over 11–13 February 2018. She sustained a hip fracture, developed bronchopneumonia and died at Willow Wood Hospice on 26 February 2018. Concerns included vulnerable residents being left unsupervised, an unclear falls assessment tool, and the absence of an investigation into Mrs Douthwaite’s 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Risk of Falls Assessment Tool failing to provide clear and consistent guidance
Wider context from the report “2. The Risk of Falls Assessment Tool currently used across HC-One’s homes was demonstrated in court to be unclear and susceptible to different interpretations . When asked about it in the course of her evidence, HC-One’s Area Director was not aware as to whether or not this Assessment Tool had recently been benchmarked as against others used within the industry;
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate repeated falls
Wider context from the report “3. Notwithstanding the fact Mrs Douthwaite had 3 falls over the course of as many days in February 2018, HC-One had not, as at the date of the Inquest, undertaken any investigation into the circumstances of these . The absence of any investigation by HC-One in this respect represents a missed opportunity to ascertain if any learning can be derived from these incidents for the benefit of other residents.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of clear written requirements for communal-area supervision
Wider context from the report “1. The evidence before the court suggested that at Greatwood House, vulnerable residents including residents with dementia such as Mrs Douthwaite, may be left unsupervised at times in communal areas by carers undertaking other tasks. The evidence before the court was that there are currently no clear written requirements in force across HC-One’s homes mandating the attendance of a colleague to monitor the communal area in question before leaving it unattended ;
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise vulnerable residents in communal areas
Wider context from the report “1. The evidence before the court suggested that at Greatwood House, vulnerable residents including residents with dementia such as Mrs Douthwaite, may be left unsupervised at times in communal areas by carers undertaking other tasks . The evidence before the court was that there are currently no clear written requirements in force across HC-One’s homes mandating the attendance of a colleague to monitor the communal area in question before leaving it unattended;
” Open source report
12 Apr 2018 Patricia Ann Heslop · Prevention of Future Deaths report Sunderland
View report summary
Concerns raised 15 Fragmented care information systems View source Failure to update care plans View source Lack of an effective observation-based early warning system View source Incomplete or inaccurate care records View source Failure to provide families with regular information about care View source Failure to collate changes in residents' presentation View source Failure to review care documentation View source Unclear responsibility for completing care forms View source Lack of comprehensive induction and ongoing dementia training View source Failure to report falls View source Failure to obtain timely witness statements after falls View source Failure to recognise the significance of changes in condition View source Failure to record changes in residents' presentation View source Delays in obtaining timely treatment View source Failure to recognise the need for hospital x-ray after suspected unwitnessed falls View source See 12 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
Patricia Ann Heslop · 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
Patricia Ann Heslop, a 75-year-old care home resident with vascular dementia, suffered an unwitnessed fall and fractured her right neck of femur. Following surgery and a period of immobility, she developed acute bronchopneumonia and died on 9 April 2017. The report raised concerns about the unreported fall, changes in mobility and presentation not being recorded or communicated, incomplete care records, delayed treatment, and staff training and information systems.
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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Fragmented care information systems
Wider context from the report “7. There were numerous forms for staff to complete and read, instead of an integrated IT system . Staff were unsure, who had to complete the forms either for themselves, or on behalf others.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to update care plans
Wider context from the report “4. There was evidence that care plans had not been updated , various documents not reviewed or read by others, as well as that records were incomplete or inaccurate. For example, the impression was given of Patricia being in a chair for 13 continuous hours and in bed for 17 hours with concerns about her fluid/nutritional intake as well as her personal needs.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of an effective observation-based early warning system
Wider context from the report “3. A number of terms were used about Patricia's developing condition: “lethargy”, “mobility fluctuating”, “gone off her feet”, “struggled to stand” and “non-weight bearing”, yet no significance was placed upon what this really meant alongside an effective early warning system associated with observations .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Incomplete or inaccurate care records
Wider context from the report “4. There was evidence that care plans had not been updated, various documents not reviewed or read by others, as well as that records were incomplete or inaccurate . For example, the impression was given of Patricia being in a chair for 13 continuous hours and in bed for 17 hours with concerns about her fluid/nutritional intake as well as her personal needs.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide families with regular information about care
Wider context from the report “2. There appears to have been a change in Patricia's presentation and a number of factors, which were not collated in the days preceding her hospital admission including:
• the unusual and regular use of a wheelchair;
• the rocking manoeuvre by two members of staff to get Patricia from her chair;
• the fact that two members of staff would walk with Patricia.
These matters were not recorded, as they ought to have been, nor were the family informed , as they should have been.
It is important that family members have confidence in the provision of care to a loved one and have regular information provided to them.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to collate changes in residents' presentation
Wider context from the report “2. There appears to have been a change in Patricia's presentation and a number of factors, which were not collated in the days preceding her hospital admission including:
• the unusual and regular use of a wheelchair;
• the rocking manoeuvre by two members of staff to get Patricia from her chair;
• the fact that two members of staff would walk with Patricia.
These matters were not recorded, as they ought to have been, nor were the family informed, as they should have been.
It is important that family members have confidence in the provision of care to a loved one and have regular information provided to them.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to review care documentation
Wider context from the report “4. There was evidence that care plans had not been updated, various documents not reviewed or read by others , as well as that records were incomplete or inaccurate. For example, the impression was given of Patricia being in a chair for 13 continuous hours and in bed for 17 hours with concerns about her fluid/nutritional intake as well as her personal needs.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Unclear responsibility for completing care forms
Wider context from the report “7. There were numerous forms for staff to complete and read, instead of an integrated IT system. Staff were unsure, who had to complete the forms either for themselves, or on behalf others .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of comprehensive induction and ongoing dementia training
Wider context from the report “8. Comprehensive induction and on-going dementia training of staff may be beneficial to better appreciate the needs of those who suffer with dementia and the communication difficulties they have.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to report falls
Wider context from the report “1. The fall was unwitnessed and went unreported .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely witness statements after falls
Wider context from the report “5. Despite Patricia having fallen sometime in the early part of November no attempts were made at that time to take statements from various witnesses about the fall while events were fresh in their memories . Instead that had to be done as part of the Inquest process. That said, if there was a reluctance to be frank and candid then it was unlikely to manifest itself at the Inquest. It was deeply disappointing that vital information was not to hand about a resident having fallen or being found or assisted after a fall, especially when Patricia had a known history of falls.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the significance of changes in condition
Wider context from the report “3. A number of terms were used about Patricia's developing condition: “lethargy”, “mobility fluctuating”, “gone off her feet”, “struggled to stand” and “non-weight bearing”, yet no significance was placed upon what this really meant alongside an effective early warning system associated with observations.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record changes in residents' presentation
Wider context from the report “2. There appears to have been a change in Patricia's presentation and a number of factors, which were not collated in the days preceding her hospital admission including:
• the unusual and regular use of a wheelchair;
• the rocking manoeuvre by two members of staff to get Patricia from her chair;
• the fact that two members of staff would walk with Patricia.
These matters were not recorded , as they ought to have been, nor were the family informed, as they should have been.
It is important that family members have confidence in the provision of care to a loved one and have regular information provided to them.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Delays in obtaining timely treatment
Wider context from the report “6. The delay in getting treatment for Patricia in a more timely way did not cause or contribute to her death, but Patricia was probably in a lot pain for longer than she needed to have been.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise the need for hospital x-ray after suspected unwitnessed falls
Wider context from the report “9. If there had been a suspicion of an unwitnessed fall, there ought to have been a realisation that an x-ray at the hospital was the only definitive and safe pathway to appropriate treatment , as opposed to examination by a nurse or GP .
” Open source report
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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 Deliver falls identification, reporting and management training, coaching and competency assessment to Hebburn Court staff, completing remaining coverage.
Verbatim wording from the response “1.6 Following this incident, action has been taken at Hebburn Court to ensure that all staff have the knowledge, skills and tools to identify, record and manage falls to reduce risk and prevent harm. All staff have been reminded of the importance of alerting nursing colleagues and managers to any fall and documenting within the individuals' records. Learning on this has been facilitated by reassignment of the falls prevention module from our award winning online learning platform, Touchstone. In addition staff have received further coaching and assessment of competencies in this area through staff meetings and individual supervision sessions. Training statistics in this area are currently 93.5% of the staff team and plans remain to press for this to increase to 100% by the end of June 2018.” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Monitor incident-investigation reporting quality and provide refreshed investigation-management training to Home Managers and Area Team Managers.
Verbatim wording from the response “5.2 HC-One has a clear incident investigation process in place as detailed in ████████ statement and above. Since this incident action has been undertaken to ensure the quality of incident investigation reporting is monitored, which has lead in turn to refreshed investigation management training. This has been provided at both Home Manager level and also as part of an 8 day intensive and practice focussed induction for Area Team Managers. This was conducted by the Head of Standards and Compliance and Leadership Development Manager for the company during March and April 2018.” Source location 2018-0102-Response-by-HC-One
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 Hebburn Court staff dementia-training modules and scheduled classroom training to achieve full compliance.
Verbatim wording from the response “8.3 Dementia Training is provided for all HC-One staff. Evidence was provided during the inquest that Dementia training formed part of the fundamental training for all carers. This includes four separate modules called, "Open Heart and Minds". Content starts with understanding dementia and the brain, the biology of dementia and the experience for the person, through to engagement and involvement of the person and their loved ones, importance of the physical environment, use of resources to delivery of person centred, informed and educated dignified care, and effective support for residents to promote their personal sense of well-being. This training is completed in 5 stages. Since this incident, HC-One has ensured that staff at Hebburn Court have all undertaken dementia training. At the time of writing, staff at Hebburn Court had” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Link training-completion monitoring to Human Resources procedures and notify or pursue disciplinary action for incomplete induction training.
Verbatim wording from the response “8.2 The Manager, with Human Resources support review training statistics for Hebburn Court and action would be taken to ensure that any individual employee who does not complete their training will receive follow up correspondence from HC-One to advise that training is required. This process is now linked to HC-One Human Resource procedures. Therefore action has been taken by HC-One to ensure staff are aware that non-completion of comprehensive induction training may result in disciplinary action of staff. Training statistics for Hebburn Court indicate that this has not been experienced since the incident, with staff embracing all learning opportunities and resultantly the statistics for the home have stabilised at a level above the minimum company expectations of 85%.” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Implement and evaluate the e.care electronic care-planning system, with organisation-wide rollout scheduled for October 2018.
Verbatim wording from the response “2.3 Significant work has been undertaken by HC-One to introduce an electronic care planning system, e.care. The pilot has continued to be implemented, evaluated and refined in a number of homes and the measurable successes achieved to date have resulted in a date for roll out across the organisation in October 2018. The electronic system will remove the requirement for paper care plans to be kept in multiple files and enable all information and care plans to be stored in one place.” Source location 2018-0102-Response-by-HC-One
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 Coach shift and Household leaders to obtain and regularly verify family contact details through the Resident of the Day process.
Verbatim wording from the response “2.9 HC-One has also undertaken additional work to ensure that shift and Household leaders have been instructed to obtain as many details of family contacts as possible and ensure that family contacts are reviewed regularly. This is being managed through individual coaching sessions by the Area Team on leading and managing and effective completion of the Resident of the Day process, which prompts the person completing to review and seek confirmation from family members or carers that details held are correct and that any specific parameters are accurate.” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Train nurses and senior care staff in the NEWS early-warning system and deliver the training to care staff.
Verbatim wording from the response “3.2 Evidence was heard during the inquest of the increased use of NEWS early warning system to enable observations to be obtained. NEWS is a well validated ‘track and trigger’ early warning score system used in the majority of UK hospitals. It is based on a simple scoring system in which a score is allocated to physiological measurements already undertaken when patients present or are being monitored in healthcare settings. Use of NEWS score assist in the identification of a sick patient. Evidence was provided that staff at Hebburn Court have now been trained in the NEWS system. All nurses and senior care staff have received training in the system and this will also then be delivered to care staff over the coming few months.” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Train care, nursing and management staff to use the e.care system effectively.
Verbatim wording from the response “2.5 As part of the implementation of the e.care system, all staff will receive training to ensure they can navigate and optimise its use to the benefit of residents and their care and support needs. Care, nursing staff and management will all have access to the system, which places the resident at the heart of the system and captures all the support needs and actions required to guide and support staff in meeting their needs. There are categories of care to help prompt appropriate assessment of need but also infinite options for adding bespoke information to inform the care planning.” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Coach and role-model staff handovers so they include all relevant information.
Verbatim wording from the response “2.10 Similarly, the Area Team have coached and role modelled good practice staff handovers at the home to ensure that handovers will include all information.” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Embed Resident of the Day quality-assurance reviews to identify changes or deterioration and monitor care and support needs.
Verbatim wording from the response “6.1 Evidence was heard during the inquest that the delay in obtaining treatment, whilst did not directly contribute to the death, did result in Mrs. Heslop being in pain for a longer period than necessary. This can be attributed to by carers and nursing staff not appropriately recognising and acting upon indicators of deterioration. The Resident of the Day reviews identify any changes or deterioration now that the quality assurance system has been reset and embedded at the home. This will be further enhanced by the e.care system, as mentioned previously in terms of robust monitoring and reviews of care and support needs.” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Contrary to the report, witness information was obtained during the initial and subsequent internal investigations.
Verbatim wording from the response “5.1 It is stated in the Regulation 28 Report that no attempts were made to take statements from individual witnesses immediately after the fall in November 2016. Immediately following the incident in November 2016, an investigation was undertaken by the then Home Manager, BJ and completed on 26 November 2016. As part of this investigation, witness information was obtained from 8 witnesses. A further investigation was undertaken by HC-One by LL, Area Director dated 7 February 2017. For the purposes of this second internal investigation 12 witnesses were re-interviewed and additional information obtained. Further witness statements were obtained for the purposes of the inquest investigation to re-examine the information and provide more comprehensive statements. It is acknowledged that none of these witness statements identified any evidence of when or how Mrs.” Source location 2018-0102-Response-by-HC-One
Open published response
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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 Terminological differences cannot all be removed and are not necessarily inappropriate, although consistent language and indicators are important.
Verbatim wording from the response “3.1 You identified that a number of terms were used regarding Mrs. Heslop’s developing condition. ████████ provided evidence during the inquest that whilst it is not possible to remove all differences in clinical description (including the use of colloquialisms and staff language) to describe a resident's individual presentation nor is it necessarily appropriate to do so, it is however important to provide consistent language and indicators which can provide an early warning system based on observations.” Source location 2018-0102-Response-by-HC-One
Open published response
11 Apr 2018 George Goldby · Prevention of Future Deaths report Nottinghamshire
View report summary
Concerns raised 12 Unavailability of SALT assessments in care plan files View source Failure to supervise residents at high risk of choking during eating View source Failure to report choking incidents in line with internal policy View source Failure to re-refer residents to SALT when indicated View source Inadequate and disorganised choking risk assessment record keeping View source Failure to adhere to SALT dietary recommendations View source Failure to review care plans and dietary requirements View source Lack of consistent and stable managerial leadership View source Lack of staff knowledge of residents at high risk of choking and supervision needs View source Failure to provide one-to-one mealtime supervision for residents at choking risk View source Inadequate and out-of-date choking risk assessments View source Lack of staff awareness of SALT supervision and dietary recommendations View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
George Goldby · 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
George Goldby choked on a sandwich on 20 March 2017, was taken to hospital, and died on 24 March 2017. The principal concerns were that staff did not follow his speech and language therapy recommendations, including one-to-one supervision and dietary requirements; choking risk assessments and care plans were inadequately managed; and choking incidents were not properly reported or followed by appropriate referrals and reviews.
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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of SALT assessments in care plan files
Wider context from the report “(6) The SALT assessment in respect of Mr Goldby had been archived and was not present on his care plan file at the time of his death.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to supervise residents at high risk of choking during eating
Wider context from the report “(8) Between 19.09.17 and 18.10.17 three separate independent professionals observed residents at high risk of choking eating alone, without supervision .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to report choking incidents in line with internal policy
Wider context from the report “(4) The choking incident on 26.12.16 was not reported in line with Stoneyford’s internal policy .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to re-refer residents to SALT when indicated
Wider context from the report “(3) There were three missed opportunities to re-refer Mr Goldby to SALT and to review his care plan and dietary requirements.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate and disorganised choking risk assessment record keeping
Wider context from the report “(5) The care plan records and in particular, the choking risk assessments in respect of Mr Goldby were inadequately completed and record keeping has been incomplete and/or wholly disorganised .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to SALT dietary recommendations
Wider context from the report “(2) Mr Goldby’s SALT recommendations were not being adhered to on 26.12.16 when he choked and recovered, nor on 20.03.17 when he choked again, directly leading to his death. Mr Goldby was not supervised one to one during his mealtimes.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to review care plans and dietary requirements
Wider context from the report “(3) There were three missed opportunities to re-refer Mr Goldby to SALT and to review his care plan and dietary requirements .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of consistent and stable managerial leadership
Wider context from the report “(11) Stoneyford care home has had a high turnover of managerial staff in the past year and this has resulted in a lack of consistency and stability . The role of home manager has yet to be permanently filled .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff knowledge of residents at high risk of choking and supervision needs
Wider context from the report “(7) Staff at the care home remain unaware of how many residents are at high risk of choking and the need for supervision .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide one-to-one mealtime supervision for residents at choking risk
Wider context from the report “(2) Mr Goldby’s SALT recommendations were not being adhered to on 26.12.16 when he choked and recovered, nor on 20.03.17 when he choked again, directly leading to his death. Mr Goldby was not supervised one to one during his mealtimes .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Inadequate and out-of-date choking risk assessments
Wider context from the report “(9) On 05.04.18 a reviewing officer from Nottinghamshire Safeguarding Team attended at the home to do a spot check and reviewed 4 files. That check revealed a choking risk assessment in respect of one of those residents which was said by the officer to be inadequate, out of date and not fit for purpose .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of staff awareness of SALT supervision and dietary recommendations
Wider context from the report “(1) The nursing home staff were unaware of the SALT recommendations regarding Mr Goldby’s need for one to one supervision and dietary requirements .
” Open source report
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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 Sustain senior management cover at the home seven days a week during the nursing-service transition.
Verbatim wording from the response “Whilst this process is being managed we have sustained senior management cover at the home 7 days a week to oversee the process.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Commission a three-day face-to-face dysphagia course for the home’s staff from an external expert provider.
Verbatim wording from the response “We believe that there is no substitute for repeated learning opportunities that help inform staff of the consequences of not supporting Residents effectively and to that end have commissioned a three day face to face dysphagia course for the staff team from an external expert training provider. This is to supplement and extend the learning opportunities already available and refreshed by the team via our online award winning learning platform, Touchstone.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Share residents’ SALT fluid and diet requirements with catering, housekeeping, care and nursing staff.
Verbatim wording from the response “5. All existing fluid/diet requirements from SALT were shared with the whole team of colleagues working at the home. This includes the catering team, as well as housekeeping, care and nursing colleagues to ensure that as one team, the staff act as additional eyes and ears to protect Residents and prevent harm.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Develop a long-term diet-notification review process and incorporate it into HC-One’s choking-risk governance strategy.
Verbatim wording from the response “The Catering Manager in the home has developed their own review process for long term updates of diet notifications where Residents care needs haven’t changed. The catering team have taken a proactive approach to the concerns raised. This process developed within Stoneyford will now form part of the governance strategy for managing the risk of choking across HC-One.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Assign the Care Manager oversight of communication and escalation between Speech and Language Therapy and home staff.
Verbatim wording from the response “4. The Care Manager has taken responsibility for oversight of communication between SALT and colleagues at the home to ensure optimum communication and appropriate escalation for support. This has been reported by all parties as very much improved, with greater clarity and swifter partnership working.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Rewrite residents’ care plans to specify detailed individual care requirements.
Verbatim wording from the response “6. Once this initial work was completed at Stoneyford, we sought advice from senior clinicians within the company for governance and oversight, which resulted in the care plans being rewritten to specify the detailed plan of care for each Resident.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 supervision to all home colleagues, identify knowledge gaps and source role-relevant learning.
Verbatim wording from the response “All colleagues working at the home have received supervision to support them with their working practices and which has led to the identification of any gaps in knowledge and sourcing of learning opportunities to support them in their roles. Areas covered have included understanding Resident’s needs, identification of changing needs, escalation processes, role profiles for each specific job, responsibilities and accountability, the vision and values of the organisation and the prioritisation of the delivery of high quality and kind care.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Introduce dining registers and quick-reference guides for managing specialist diets, with formal review and update governance.
Verbatim wording from the response “7. Additional advice was sought from the company Hospitality specialist to establish if there were any further processes or mechanisms to help support the safe and effective management of people who require a specialist diet. As a result we have introduced a new system of dining registers with quick reference guides, which were put into place and help colleagues or any agency workers to reflect the handover documentation.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Allocate staff and provide practical supervision during residents’ eating and drinking.
Verbatim wording from the response “1. Allocation of staff to and practical supervision of Residents whilst eating and drinking to assess any issues.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Implement and embed the required hospitality policy and process with kitchen staff.
Verbatim wording from the response “The hospitality specialist has supported the home and worked with colleagues working in the kitchen to implement and embed the policy and process that is required to be in place.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Maintain a registered Senior Turnaround Manager and appoint a Care Manager to progress and embed planned actions across seven days and nights.
Verbatim wording from the response “There is a registered manager in place who is a Senior Turnaround Manager and a newly appointed Care Manager whose background is in Residential care services. As mentioned, this team has been working across 7 days/nights to ensure the actions we have planned are being progressed and embedded with the care team.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Refer residents meeting the threshold to Speech and Language Therapy and schedule required follow-up reviews.
Verbatim wording from the response “3. All Residents whose assessment indicated having reached the appropriate threshold of need have been referred to the Speech and Language team (SALT) service via the GP for review- New referrals have also been actioned and follow-ups reviews have been planned by SALT- 2 existing Residents are due a review, which have been scheduled.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 Implement daily ‘Resident of the day’ care-plan reviews and report changing needs through the clinical risk register.
Verbatim wording from the response “8. The manager and staff at the home have implemented a ‘Resident of the day’ approach to care plan reviews which means that a designated Resident has their care and support needs reviewed every day to ensure any changes are reflected in updated care plans and shared with colleagues who support them. Any changes in need are reported monthly through to the clinical risk register, which is monitored by the Senior Turnaround Manager working at the home and the Area quality management Team.” Source location 2018-0104-Response-by-HC-One
Open published response
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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 swallowing risk assessments with independent validation and Care Manager sign-off of updates.
Verbatim wording from the response “2. Completion of the swallowing risk assessment with independent validation from another senior colleague to ensure accurate scoring and corresponding actions to mitigate risk are adhered to. This system remains in place with the Care Manager reviewing and signing off any updates.” Source location 2018-0104-Response-by-HC-One
Open published response
Concerns raised 1 Failure to account for and query excess resident medication 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.
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AI-generated summary
Marie Quinn, otherwise known as Marie Pearson Quinn · 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
Marie Quinn fell at home on 20 May 2015, sustained a fractured right neck of femur, underwent surgery, and died in hospital on 13 July 2015 after becoming unwell. The report identified concerns about sub-optimal deep venous thrombosis prophylaxis and medication management at Richmond House Nursing Home, including inaccurate instructions and unaccounted-for excess medication.
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× 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to account for and query excess resident medication
Wider context from the report “2. I have concerns with regard to the following:
i. The management of the medication for the residents at Richmond House Nursing Home.
ii. Evidence was given at the Inquest that there are occasions where Richmond House Nursing Home are left with excess medication that is prescribed to, or directed to be taken by, a resident in their care . This medication should be accounted for and should therefore be queried as residents may not be given medication in circumstances where they should be . I therefore request that Richmond House Nursing Home, which is governed by HC-One Limited, review their policies and procedures regarding the management of the medication prescribed to their residents.
” Open source report
2 Jul 2014 ALBERT FLYNN · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure to provide food and fluid during prolonged care periods View source Failure to administer prescribed medication View source Insufficient staff training and qualification for assessment and treatment decisions View source Failure to account for recent blood-thinning medication in assessment View source See 1 more concern
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
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AI-generated summary
ALBERT FLYNN · 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
Albert Flynn, a resident of Appleton Manor Residential Home, was taken to hospital with a suspected deep vein thrombosis and treated with the blood-thinning drug Enoxaparin. The following night he was left in a chair for approximately 10 hours without food, fluids or prescribed medication, while staff were unable to rouse him. He was suffering from a severe cerebral bleed, which was fatal; concerns included inadequate staff training and failure to recognise the significance of his condition and recent blood-thinning treatment.
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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide food and fluid during prolonged care periods
Wider context from the report “1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated.
2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours .
3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day.
4. The staff did not seem to appreciate the importance of administering prescribed medication.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to administer prescribed medication
Wider context from the report “1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated.
2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours .
3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day.
4. The staff did not seem to appreciate the importance of administering prescribed medication .
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Insufficient staff training and qualification for assessment and treatment decisions
Wider context from the report “1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated .
2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours.
3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event , nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day.
4. The staff did not seem to appreciate the importance of administering prescribed medication.
” 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 Hc-One Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to account for recent blood-thinning medication in assessment
Wider context from the report “1. Whilst the care staff members were apparently concerned as to the condition of Mr Flynn, none of them was sufficiently well trained or qualified to make an informed decision as to how he should be treated.
2. As a result of the above, he was left sitting in a chair, partially dressed, without food, fluid or medication for a period of approximately 10 hours.
3. None of the staff gave any indication of any, or any proper, training in the assessment of this type of event, nor did they attribute any or any sufficient weight to the fact that he had been administered blood thinning drugs the previous day .
4. The staff did not seem to appreciate the importance of administering prescribed medication.
” Open source report
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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 Re-emphasise the need to seek qualified advice during induction training for new staff.
Verbatim wording from the response “On this particular occasion the care staff members were experienced care assistants, some of whom had undergone NVQ training and had also undertaken mandatory training courses in relation to certain aspects of the delivery of care. As a matter of routine all care staff receive training in essential elements of care and these include Safer people handling; Safeguarding; Emergency procedures; Falls awareness; Promoting healthy skin. It is accepted that in this particular case Mr Flynn was left undisturbed for too long before qualified assistance was sought and during induction training for new staff, the need to call for qualified advice will be re-emphasised.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
Open published response
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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 additional training and competency assessment to the senior carer involved in the incident.
Verbatim wording from the response “The importance of medication being provided at the appropriate time is something that is contained in the routine training and competency assessments undertaken by staff and repeated at annual intervals but conducted more frequently should individual concerns be raised. Senior carer staff involved in this incident will undergo additional training and competency assessment to support her awareness.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
Open published response
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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 Re-emphasise earlier help-seeking and intervention to the care staff involved through supervision.
Verbatim wording from the response “The circumstances surrounding the care staff’s failure to alert the qualified nurse on duty of Mr Flynn’s condition is regrettable and with the balance of hindsight is accepted by them as having been regrettable. The need to seek earlier help and intervention has been re-emphasised to all the care staff involved in this case during the course of supervision and this case will also serve as a reminder to all care staff working within the company to alert more senior staff should they have any cause for concern about the condition of a resident which is unexpected or extraordinary.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
Open published response
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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 Use the case as a reminder to all company care staff to alert senior staff about unexpected or extraordinary resident conditions.
Verbatim wording from the response “The circumstances surrounding the care staff’s failure to alert the qualified nurse on duty of Mr Flynn’s condition is regrettable and with the balance of hindsight is accepted by them as having been regrettable. The need to seek earlier help and intervention has been re-emphasised to all the care staff involved in this case during the course of supervision and this case will also serve as a reminder to all care staff working within the company to alert more senior staff should they have any cause for concern about the condition of a resident which is unexpected or extraordinary.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
Open published response
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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 Qualified nursing input for residential clients would normally be provided by the district nursing service, rather than residential care staff.
Verbatim wording from the response “Mr Flynn’s condition should have been addressed at that stage. The nurse on duty would then have been able to attribute proper weight to the fact that Mr Flynn had received blood thinning drugs the previous day and his state of consciousness was cause for concern. The hospital did not provide any cautionary advice for the care team upon discharge back to the home on the evening of 14th March 2014 following the administration of anti-coagulation therapy, nor did the hospital initiate district nursing input across the weekend. Mr Flynn was accommodated as a residential client and so his day to day care would not have been provided by qualified nurses but by care assistants. The nursing input would normally be provided by the district nursing service.” Source location 2014-0308-Response-by-Lester-Aldridge-LLP
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations