Recipient

Lukka Care Homes Limited

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First report 9 Apr 2025•Latest report 9 Apr 2025

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. 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 Lukka Care Homes Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Ivy May DIXON · 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

    Ivy Dixon choked on food while being fed by staff at Acorn Lodge Care Home on 6 October 2024, causing cardiac arrest. Staff did not perform CPR, and concerns were raised about inaccurate communication to paramedics, staff integrity, and possible training or clinical skills gaps in emergency care.

    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 Lukka Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake CPR during cardiac arrest from a potentially reversible cause

    Wider context from the report

    “2. While the patient was breathing and conscious at the time of the 999 call, when LAS staff attended six minutes later, the patient was not conscious, not breathing, had no palpable pulse, and was critically unwell in confirmed cardiac arrest. However, despite this, staff from the Care Home were not undertaking CPR. The DNACPR would not have applied in this case, because choking is a potentially reversible cause of cardiac arrest, which the Care Home’s manager confirmed in her evidence. This raises the concern that staff (healthcare assistants and nursing staff) at the Care Home may have previously unidentified training needs and/or lacked the clinical skills/knowledge to provide emergency care. ”
    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 Lukka Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of healthcare assistant and nursing staff training and clinical skills or knowledge for emergency care

    Wider context from the report

    “2. While the patient was breathing and conscious at the time of the 999 call, when LAS staff attended six minutes later, the patient was not conscious, not breathing, had no palpable pulse, and was critically unwell in confirmed cardiac arrest. However, despite this, staff from the Care Home were not undertaking CPR. The DNACPR would not have applied in this case, because choking is a potentially reversible cause of cardiac arrest, which the Care Home’s manager confirmed in her evidence. This raises the concern that staff (healthcare assistants and nursing staff) at the Care Home may have previously unidentified training needs and/or lacked the clinical skills/knowledge to provide emergency care. ”
    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 Lukka Care Homes Limited; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide consistent and accurate communication about patient care

    Wider context from the report

    “1. The healthcare assistant who had been with Mrs Dixon on the evening of 6 October 2024, clearly referred in her statement to the patient having been fed. Shortly thereafter the healthcare assistant heard “a noise” coming from the patient’s chest and so she called for the assistance of a nearby nurse. Two nurses attended and made the reasonable assumption that the patient was choking. Treatment was administered and a set of vital observations showed that the patient’s oxygen saturations were 87%. On this basis, nursing staff called for an emergency ambulance: the London Ambulance Service (LAS) call handler was told that the patient was “choking” albeit she was breathing and conscious at that time. Despite this, once LAS staff arrived at Acorn Lodge Care Home, the Care Home staff told paramedics that they had been attempting to feed the patient, but the patient started to gasp before any food was given to her, meaning they were unable to feed her. This raises concerns about the communication and integrity of the staff members at the Care Home in their provision of care to the patient. I did not receive any reassurance that this concern has been addressed. ”
    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