Recipient

Highgrove Rest Home

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First report 14 Jul 2023•Latest report 14 Jul 2023

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

Reports over time

Reports naming this recipient by issue year.

Evidence profile

Report topics

Share of this recipient’s reports compared with all other recipients.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Highgrove Rest Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Blackpool and the Fylde

    AI-generated summary

    Mr Terence Burns · Prevention of Future Deaths report

    This summary was generated using AI from the published report. Please read the original report for the complete account.

    Report summary

    Mr Terence Burns, a resident of Highgrove Rest Home, was transferred to hospital on 28 October 2022 after his physical condition deteriorated. His blended-diet requirement was not communicated to ambulance services or the hospital, and he was later found unresponsive with food residue in his throat and died. Concerns included inaccurate care-plan information about his nutritional needs and failure to check the documents handed over during transfer.

    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 Highgrove Rest Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain care plans with accurate nutritional requirements

    Wider context from the report

    “The written care plan that was in place at Highgrove Rest Home did not contain the information that Mr Burns required a blended diet. Having heard the oral evidence from the two carers who attended the inquest to give evidence, I accepted that Mr Burns was being fed a blended diet in advance of his attendance at hospital on 28 October 2022. I found that the monthly reviews of the care plan, that were carried out on 4 September and 8 October 2022, did not amend the care plan to include the need for a blended diet, and accordingly the written care plan did not accurately define the nutritional needs of Mr Burns. This missing information from the care plan was a concern for me as the documentary evidence relating to the nutritional requirements of Mr Burns was not correct. ”
    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 Highgrove Rest Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check care information handed over during hospital transfers

    Wider context from the report

    “Furthermore, I was concerned that the oral evidence that I heard at the inquest, established that the documents handed over to North West Ambulance Services when Mr Burns was taken to hospital, were not checked. When Mr Burns was taken to hospital, it could not be ascertained what information was sent with Mr Burns to enable the hospital to meet his care needs. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026