Recipient

Jubilee Gardens

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First report 13 Oct 2016•Latest report 13 Oct 2016

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 Jubilee Gardens linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Birmingham and Solihull

    AI-generated summary

    Robert Arthur Davidson · 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 Arthur Davidson, who had dementia, Alzheimer’s disease and PICA, died after choking on a plastic glove at a care home on 27 January 2016. The report identified concerns about inadequate transfer of information about his PICA, insufficient staff training and failures in emergency procedures, including calling emergency services and initiating CPR.

    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 Jubilee Gardens; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to train care staff in basic emergency call processes

    Wider context from the report

    “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows: • Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient. • When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations. ”
    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 Jubilee Gardens; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of objectively assessed basic training and competence standards for HCAs

    Wider context from the report

    “2. The two HCA’s had no experience or basic training before starting work as HCA’s. They had limited understanding of conditions and processes. Consideration needs to be given as to whether there should be mandatory training or minimum standards, which are objectively assessed, to ensure HCA’s have the necessary knowledge and understanding to undertake their role. ”
    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 Jubilee Gardens; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to train care staff in CPR and choking procedures

    Wider context from the report

    “1. During the inquest I heard evidence that Health care staff had not been trained on basic process as follows: • Making 999 calls – to obtain an outside line caller’s needed to first dial “9”. The HCA instructed to make the 999 call did not know this so the call was unsuccessful. The registered nurse looking after the patient whilst he was choking had to make the 999 call resulting in her leaving the patient. • When to Start CPR. The RGN and HCA (Health Care Assistants) staff had received no training on the CPR and choking policy The concern is that staff are not trained in basic processes and therefore not able to deal with emergency situations. ”
    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 Jubilee Gardens; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to highlight essential patient information during transfers between care homes

    Wider context from the report

    “3. The deceased PICA behaviour was not highlighted or identified on his transfer between care homes. Some process or direction from the governing body needs to be provided to care homes to ensure essential information is provided and highlighted when patients are transferred. ”
    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