12 Sep 2014 Barbara Monica May Cooke · Prevention of Future Deaths report Isle of Wight
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Concerns raised 6 Lack of a protocol for chasing up unresponded District Nurse Service messages View source Failure to recognise infection risks from leaving incontinent residents in their own waste View source Inadequate staffing levels for meeting residents’ care, medication, comfort and dignity needs View source Lack of admission recording of open safeguarding concerns View source Lack of automatic coroner referral for deaths of inpatients subject to safeguarding alerts View source Lack of automatic safeguarding-team notification of deaths of inpatients subject to open safeguarding alerts View source See 3 more concerns
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
Barbara Monica May Cooke · 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
Barbara Monica May Cooke, an 84-year-old resident of Waxham House Residential Care Home, developed severe pressure ulcers, sepsis and multiple organ failure, and died in hospital on 11 April 2014. The report raised concerns about inadequate staffing, delays in toileting and cleaning, failure to recognise and manage infection risks associated with pressure sores, and gaps in communication and safeguarding procedures after her admission and death.
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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 Isle of Wight Adult Safeguarding Team; that does not assign responsibility.
PFD Monitor interpretation Lack of a protocol for chasing up unresponded District Nurse Service messages
Wider context from the report “3. I am concerned that there appears to be no protocol at Waxham House to chase up the District Nurse Service if they haven’t responded to a message within 24
” 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 Isle of Wight Adult Safeguarding Team; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise infection risks from leaving incontinent residents in their own waste
Wider context from the report “2. I am concerned that the Waxham House Residential Care Home didn’t recognise the obvious risks of infection of leaving an incontinent lady sitting in her own waste when she was prone to sacral sores , and almost certainly had at least one at the point at which she was left sitting in her own urine and excrement for two and half hours on 30th March 2014.
” 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 Isle of Wight Adult Safeguarding Team; that does not assign responsibility.
PFD Monitor interpretation Inadequate staffing levels for meeting residents’ care, medication, comfort and dignity needs
Wider context from the report “1. During the course of the evidence, it became clear that the resident to staff ratio of 20:2 during between 2 p.m. and 9 p.m. was inadequate to deal with all the residents’ needs at Waxham House. (The staffing levels at other times also appeared inadequate for the numbers of residents .) The staffing levels did not allow for one staff member to safely distribute medication to the residents without interruption ; provide teas for the residents and cater for their other reasonable needs in an acceptable timeframe. I was concerned that residents were being left for two and a half hours, sitting in their own excrement, waiting to be taken to the toilet and cleaned, and that there were insufficient staff to attend to a resident who was clearly dying . Moreover, I am concerned that there were insufficient staff members to escort residents away from a resident who was being attended to by paramedics , thereby denying this lady any dignity in her last moments.
” 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 Isle of Wight Adult Safeguarding Team; that does not assign responsibility.
PFD Monitor interpretation Lack of admission recording of open safeguarding concerns
Wider context from the report “4. I am concerned that there does not appear to be a system in place at St Mary’s Hospital to record on admission that a patient is the subject of an open Safeguarding concern . (In this case, the subject of the Safeguarding alert was an adult, but this concern relates to both adults and children.)
” 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 Isle of Wight Adult Safeguarding Team; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic coroner referral for deaths of inpatients subject to safeguarding alerts
Wider context from the report “5. I am further concerned that there is currently no system in place at St Mary’s Hospital to automatically contact the Coroner to refer the matter for investigation when a person who is the subject of a Safeguarding alert dies whilst an inpatient in the Hospital .
” 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 Isle of Wight Adult Safeguarding Team; that does not assign responsibility.
PFD Monitor interpretation Lack of automatic safeguarding-team notification of deaths of inpatients subject to open safeguarding alerts
Wider context from the report “6. I am concerned that there is currently no system in place at St Mary’s Hospital to automatically notify the IOW Safeguarding Team if someone who is the subject of an open safeguarding alert dies whilst an inpatient in the Hospital .
” 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