Recipient

Meadow House

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First report 11 Mar 2024•Latest report 11 Mar 2024

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

  1. Coventry

    AI-generated summary

    Ronald James JEPSON · 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

    Ronald James Jepson, who resided at a mental healthcare facility and had a known risk of choking, suffered an unwitnessed choking episode after being provided with supper and died in hospital on 15 March 2023. Concerns included delayed and suboptimal CPR, staff calling 111 rather than 999, and infrequent and ineffectual emergency training for care home staff.

    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 Meadow House; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to identify emergencies and contact the appropriate emergency service

    Wider context from the report

    “i. Timely and commensurate interventions of care staff can have a significant positive bearing upon the outcome of a choking episode. Training on how to deal with emergency situations is not ingrained in care home staff. ii. The circumstances of this inquest touching upon the death of Ronald JEPSON accentuated this point. The evidence was that Mr Jepson 'gargling' and becoming unresponsive was an emergency. 111 (a non-emergency number) was called by care home staff and not 999. iii. A call handler recognising it was an emergency escalated matters and guidance was given to care staff as to CPR. First attempts as resuscitation by care staff were following an appreciable period of time (ascribed to inexperience and panic) and the cardiopulmonary resuscitation was sub optimal. iv. The removal of the food occluding the airway of Mr Jepson and effective CPR was provided by paramedics immediately lead a reduced cyanosis. v. A choking episode, of itself, is a time critical event. vi. Such training at the time of the incident was ineffectual and infrequent (online) with the consequence being that when an emergency arose the actions of staff to aid a resident were cumulatively sub optimal. vii. Following the incident there has been no significant increase in training frequency such as would better enable commensurate training to be ingrained in staff which may make significant difference in averting an adverse outcome for a resident in need of emergency care/ assistance. ”
    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 Meadow House; that does not assign responsibility.

    PFD Monitor interpretation

    Delays in commencing and deficiencies in the quality of CPR by care staff

    Wider context from the report

    “i. Timely and commensurate interventions of care staff can have a significant positive bearing upon the outcome of a choking episode. Training on how to deal with emergency situations is not ingrained in care home staff. ii. The circumstances of this inquest touching upon the death of Ronald JEPSON accentuated this point. The evidence was that Mr Jepson 'gargling' and becoming unresponsive was an emergency. 111 (a non-emergency number) was called by care home staff and not 999. iii. A call handler recognising it was an emergency escalated matters and guidance was given to care staff as to CPR. First attempts as resuscitation by care staff were following an appreciable period of time (ascribed to inexperience and panic) and the cardiopulmonary resuscitation was sub optimal. iv. The removal of the food occluding the airway of Mr Jepson and effective CPR was provided by paramedics immediately lead a reduced cyanosis. v. A choking episode, of itself, is a time critical event. vi. Such training at the time of the incident was ineffectual and infrequent (online) with the consequence being that when an emergency arose the actions of staff to aid a resident were cumulatively sub optimal. vii. Following the incident there has been no significant increase in training frequency such as would better enable commensurate training to be ingrained in staff which may make significant difference in averting an adverse outcome for a resident in need of emergency care/ assistance. ”
    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 Meadow House; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide sufficiently frequent and effective emergency response training for care home staff

    Wider context from the report

    “i. Timely and commensurate interventions of care staff can have a significant positive bearing upon the outcome of a choking episode. Training on how to deal with emergency situations is not ingrained in care home staff. ii. The circumstances of this inquest touching upon the death of Ronald JEPSON accentuated this point. The evidence was that Mr Jepson 'gargling' and becoming unresponsive was an emergency. 111 (a non-emergency number) was called by care home staff and not 999. iii. A call handler recognising it was an emergency escalated matters and guidance was given to care staff as to CPR. First attempts as resuscitation by care staff were following an appreciable period of time (ascribed to inexperience and panic) and the cardiopulmonary resuscitation was sub optimal. iv. The removal of the food occluding the airway of Mr Jepson and effective CPR was provided by paramedics immediately lead a reduced cyanosis. v. A choking episode, of itself, is a time critical event. vi. Such training at the time of the incident was ineffectual and infrequent (online) with the consequence being that when an emergency arose the actions of staff to aid a resident were cumulatively sub optimal. vii. Following the incident there has been no significant increase in training frequency such as would better enable commensurate training to be ingrained in staff which may make significant difference in averting an adverse outcome for a resident in need of emergency care/ assistance. ”
    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