20 Aug 2015 Elsie Clarke · Prevention of Future Deaths report Manchester South
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Concerns raised 12 Failure of Out of Hours doctors to keep proper timed attendance records View source Failure to provide appropriate advice on calling the Coroner or police View source Failure to maintain food and hydration records View source Failure to arrange GP attendance for residents not fully registered with a local GP View source Lack of understanding of prompt Care Quality Commission reporting requirements View source Gap in Out of Hours doctors’ training on reporting deaths to the Coroner View source Failure to seek assessment from an available visiting GP View source Lack of staff training in appropriate use of 999 or 111 View source Failure to keep proper and sufficient resident care notes View source Failure to provide full and effective shift handover View source Failure of Out of Hours doctors to carry or wear a watch for vital-sign assessment View source Poor observation of residents’ basic needs View source See 9 more concerns
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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
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations