Hurst Hall

Private and voluntary organisations · Residential care home

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First report 20 Aug 2015•Latest report 20 Aug 2015

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

20 Aug2015
Manchester South
Concerns raised12
1. Failure of Out of Hours doctors to keep proper timed attendance records
2. Failure to provide appropriate advice on calling the Coroner or police
3. Failure to maintain food and hydration records
1. Failure to arrange GP attendance for residents not fully registered with a local GP
2. Lack of understanding of prompt Care Quality Commission reporting requirements
3. Gap in Out of Hours doctors’ training on reporting deaths to the Coroner
4. Failure to seek assessment from an available visiting GP
5. Lack of staff training in appropriate use of 999 or 111
6. Failure to keep proper and sufficient resident care notes
7. Failure to provide full and effective shift handover
8. Failure of Out of Hours doctors to carry or wear a watch for vital-sign assessment
9. Poor observation of residents’ basic needs
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Elsie Clarke · 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

Elsie Clarke was a resident at Hurst Hall care centre and developed significant pneumonia on 10 February 2015, dying later that day. The report identified concerns about missed opportunities to summon medical help, inadequate staff training and observations, failures in record-keeping and handover, and deficiencies in out-of-hours medical processes and death reporting.

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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure of Out of Hours doctors to keep proper timed attendance records
Wider context from the report
“(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide appropriate advice on calling the Coroner or police
Wider context from the report
“(10) The doctor advised the Home that in the present case there was no need to call the Coroner/police ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain food and hydration records
Wider context from the report
“(6) There was a complete failure to maintain food and hydration records. ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to arrange GP attendance for residents not fully registered with a local GP
Wider context from the report
“(2) The staff did not know how to arrange for the attendance of a GP for a resident who was not yet fully registered with a local GP. In particular they appeared completely ignorant of the existence of a “Temporary GP Registration form”. ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Lack of understanding of prompt Care Quality Commission reporting requirements
Wider context from the report
“(4) There seemed to be a complete lack of understanding about the legal requirement for prompt reporting of such matters as occurred in this case to the Care Quality Commission. ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Gap in Out of Hours doctors’ training on reporting deaths to the Coroner
Wider context from the report
“(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to seek assessment from an available visiting GP
Wider context from the report
“(5) When a local GP was visiting another patient at the Home, the staff seemed unaware that they could and should have asked that doctor to look at this patient/resident. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Lack of staff training in appropriate use of 999 or 111
Wider context from the report
“(1) There was an apparent lack of training for the staff at Hurst Hall in the appropriate use of calling either 999 or 111. ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to keep proper and sufficient resident care notes
Wider context from the report
“(7) There was a failure to keep proper and sufficient notes of the care afforded to each resident. ”
Open source report
Source evidence
How this individual concern was interpreted
PFD Monitor created a concise, searchable interpretation from the report wording shown below. The report was sent to Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide full and effective shift handover
Wider context from the report
“(8) There was a failure to give full and effective “hand-over” at each shift change. ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Failure of Out of Hours doctors to carry or wear a watch for vital-sign assessment
Wider context from the report
“(9) There was an obvious gap in the training of Out of Hours doctors in a number of aspects including (a) Keeping proper timed records of each attendance on a patient (b) Wearing or carrying a watch so as to be able to assess pulse rates, respiration rates etc. (c) Process for reporting deaths as necessary to the Coroner ”
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 Hurst Hall; that does not assign responsibility.
PFD Monitor interpretation
Poor observation of residents’ basic needs
Wider context from the report
“(3) The level and quality of observation of the residents were very poor and did not include even some of the most basic issues such as whether the patient was warm, thirsty etc. ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised12

Failure of Out of Hours doctors to keep proper timed attendance records

Failure to provide appropriate advice on calling the Coroner or police

Failure to maintain food and hydration records

Failure to arrange GP attendance for residents not fully registered with a local GP

Lack of understanding of prompt Care Quality Commission reporting requirements

Gap in Out of Hours doctors’ training on reporting deaths to the Coroner

Failure to seek assessment from an available visiting GP

Lack of staff training in appropriate use of 999 or 111

Failure to keep proper and sufficient resident care notes

Failure to provide full and effective shift handover

Failure of Out of Hours doctors to carry or wear a watch for vital-sign assessment

Poor observation of residents’ basic needs