Monkstone House

Private and voluntary organisations · Nursing home

Pin Request correction

First report 28 Aug 2013•Latest report 28 Aug 2013

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

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

  1. Powys, Bridgend and Glamorgan Valleys

    AI-generated summary

    Terrance O’Connell · 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

    Terrance O’Connell was admitted to a care home for respite and later developed abdominal and penile pain with reduced catheter drainage. After a communication breakdown, he was not seen by clinical staff and was found extremely unwell two days later; he was diagnosed with sepsis from a urinary tract infection and died that evening. Concerns included failures in communication, monitoring of oral and urinary output, and clinical assessment, with the inquest conclusion stating that the infection went undiagnosed and untreated before hospital admission and that his condition was contributed to by neglect.

    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 Monkstone House; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of communication between the care home, district nurses and out of hours GP

    Wider context from the report

    “(1) There was a communication breakdown between the care home, district nurses and out of hours GP on the 3rd May 2013 resulting in Mr O’Connell not being seen by any clinical staff. ”
    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 Monkstone House; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to provide timely clinical assessment of a patient's condition

    Wider context from the report

    “(3) Mr O’Connell did not have any clinical assessment of his condition for 2 days until his admission to 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 Monkstone House; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of direct monitoring of oral input and urinary output at the care home

    Wider context from the report

    “(2) There was no direct monitoring of his oral input and urinary output at the care home which would have provided further evidence in support of a urinary tract infection. ”
    Open source report
Back to top

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