14 Aug 2023 Linda Oldland · Prevention of Future Deaths report Surrey
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Concerns raised 5 Failure to accurately communicate DNAR status to the ambulance service View source Failure to recognise cardiac arrest View source Delays in starting stand-by oral antibiotics View source Failure to pass pertinent information to the ambulance service View source Failure to pass pertinent clinical information to the GP View source See 2 more concerns
Responses linked to these concerns
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Linda Oldland · 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
Linda Oldland died at Hydon Hill Nursing Home on 3 January 2022 from a urinary tract infection that infected both kidneys and resulted in sepsis. Concerns included failures to share information about positive urine tests and the GP’s treatment plan, delayed antibiotics, failure to recognise cardiac arrest, and incorrectly informing ambulance staff that a valid DNAR form was in place.
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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 Leonard Cheshire Disability; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately communicate DNAR status to the ambulance service
Wider context from the report “Hydon Hill Nursing Home:
- Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021;
- Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022;
- Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis;
- Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022;
- Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022 .
The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters.
” 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 Leonard Cheshire Disability; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise cardiac arrest
Wider context from the report “Hydon Hill Nursing Home:
- Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021;
- Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022;
- Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis;
- Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022 ;
- Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022.
The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters.
” 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 Leonard Cheshire Disability; that does not assign responsibility.
PFD Monitor interpretation Delays in starting stand-by oral antibiotics
Wider context from the report “Hydon Hill Nursing Home:
- Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021;
- Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022 ;
- Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis;
- Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022;
- Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022.
The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters.
” 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 Leonard Cheshire Disability; that does not assign responsibility.
PFD Monitor interpretation Failure to pass pertinent information to the ambulance service
Wider context from the report “Hydon Hill Nursing Home:
- Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021;
- Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022;
- Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis ;
- Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022;
- Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022.
The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters.
” 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 Leonard Cheshire Disability; that does not assign responsibility.
PFD Monitor interpretation Failure to pass pertinent clinical information to the GP
Wider context from the report “Hydon Hill Nursing Home:
- Did not pass on pertinent information to the GP about the positive dip stick test on 30 December 2021 ;
- Delayed the start of the stand-by oral antibiotics from the evening 31 December 2021 until Midday on 2 January 2022;
- Did not pass on pertinent information to the ambulance service on 2 January 2022 about Mrs Oldland’s wishes and the GP plan should she deteriorate with suspected sepsis;
- Did not recognise that Ms Oldland was in a state of cardiac arrest on 3 January 2022;
- Incorrectly informed the ambulance service that Mrs Oldland had a valid DNAR in place on 3 January 2022.
The Coroner considers that consideration ought to be given to updating policies and procedures in respect of the sharing and documentation of information relating to residents and/or in relation to training of clinical staff to address the above matters.
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement an additional discreet system at Hydon Hill to identify people who do not want resuscitation.
Verbatim wording from the response “In addition to the action plan above, we have a robust handover process which is an opportunity to discuss any concerns the nurses and carers have with people, which people have a Respect document in-situ and who does not want to be resuscitated. Hydon Hill specifically have implemented an additional system to identify discreetly who does not want to be resuscitated, this ensures that if a person is not in their bedroom but around the home in their wheelchair, staff can easily identify them, should they need to.” Source location Response from Leonard Cheshire
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide sourced vital-signs training information to current clinical staff and new clinical starters.
Verbatim wording from the response “Action | Impact | Expected Completion
Weekly clinical governance meeting (continued) | personal care plans or updates which may be needed. |
Sepsis training | We have implemented Sepsis training w/c 2/10/23 and all staff have a deadline of 30th Dec to complete. | 30/12/23
Vital signs training | We have sourced further information which will be given to all clinical staff currently in post and to all clinical new starters | 30/11/23
Review of our training | We are currently reviewing our training to ensure that we offer all necessary courses to meet the needs of people we support. Any courses we do not currently have, either write them or source externally.” Source location Response from Leonard Cheshire
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Hold a daily flash meeting to discuss activities, concerns, changes in behaviour, illness and professional contacts.
Verbatim wording from the response “Action | Impact | Expected Completion
Manager’s daily walkaround | The service manager’s now carry out a daily walkaround which is documented, following a standardised format. This ensures that they are visible, speak with staff and people being supported. | Completed
Daily ‘flash’ meeting | This is a 10-20 minute meeting held daily in the morning, chaired by the Service Manager/Deputy Manager or Nurse in Charge, its attended by key staff: Domestic, Maintenance, Activities, Nurses – at the meeting the daily activities are discussed along with any concerns regarding people using the service, changes in behaviour, signs of illness, external professionals visiting, GP contact | Completed
Weekly clinical governance meeting | These meetings are held with the clinical team, going into detail about clinical concerns within the service, any further support the people we support may need.” Source location Response from Leonard Cheshire
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Maintain a robust handover process for communicating concerns about supported people.
Verbatim wording from the response “In addition to the action plan above, we have a robust handover process which is an opportunity to discuss any concerns the nurses and carers have with people, which people have a Respect document in-situ and who does not want to be resuscitated. Hydon Hill specifically have implemented an additional system to identify discreetly who does not want to be resuscitated, this ensures that if a person is not in their bedroom but around the home in their wheelchair, staff can easily identify them, should they need to.” Source location Response from Leonard Cheshire
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations