Concerns raised 16 Inadequate recording of food and fluid intake View source Failure to obtain full details before closing Adult Protection investigations View source Failure to refer for dietetic assessment after considerable weight loss View source Failure to verify correct pressure mattress function View source Inadequate staff training in pressure mattress management View source Delays in referral to Tissue Viability Nurses View source Inadequate staff training in record keeping View source Failure to maintain continence-related cleanliness before specialist assessment View source Poor continuity of care staff View source Failure to record identified pressure mattress faults View source Failure to identify staff completing care records View source Failure to record declined interventions View source Unavailability of nursing staff for Tissue Viability Nurse calls View source Failure of staff to appreciate the importance of prescribed nutritional supplements View source Failure to carry out pressure sore repositioning plans View source Falsification of pressure sore repositioning records View source See 13 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Janine Eugenie Pierrette KAISER · 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
Janine Eugenie Pierrette KAISER died at a nursing home on 21 October 2014 from lobar pneumonia, with suppurative cystitis, a sacral pressure ulcer, aortic stenosis, multiple myeloma and stroke also recorded. The principal concerns included missed turns, inaccurate or falsified records, inadequate pressure-mattress checks, poor recording of food and fluid intake, inadequate staff training and continuity, delayed referral to tissue viability nurses, and insufficient response to weight loss and safeguarding concerns. The inquest concluded that she died from significant natural disease, with a contributing sacral ulcer whose progress had been compromised by gaps in nursing 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of food and fluid intake
Wider context from the report “2. Records were difficult to interpret and did not accurately record times at which fluid and food had been offered to the deceased. The amounts taken by the deceased were not adequately recorded.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain full details before closing Adult Protection investigations
Wider context from the report “9. Single agency staff investigating Adult Protections Referrals had closed their investigation and recorded the allegations as unsubstantiated without obtaining full details of concerns raised by other professionals.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to refer for dietetic assessment after considerable weight loss
Wider context from the report “7. The deceased had lost a considerable amount of weight but there was no referral to a dietician (although the GP had been consulted regarding her weight loss and had prescribed supplements) The importance of the supplements was not fully appreciated by all of the staff. The deceased’s weight was maintained during a hospital stay but deteriorated on her return to New Park Nursing Home
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to verify correct pressure mattress function
Wider context from the report “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off . The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in pressure mattress management
Wider context from the report “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to Tissue Viability Nurses
Wider context from the report “6. Referral to Tissue Viability nurses should have been done sooner.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate staff training in record keeping
Wider context from the report “3. Staff appeared inadequately trained in record keeping.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain continence-related cleanliness before specialist assessment
Wider context from the report “8. The deceased was incontinent and had required cleaning before Tissue Viability Nurses were able to examine her.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Poor continuity of care staff
Wider context from the report “4. There was poor continuity of 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to record identified pressure mattress faults
Wider context from the report “5. Twice daily pressure mattress checks were fully completed indicating an appropriately functioning mattress. However when a mattress check was made by Tissue Viability Nurses the mattress was not alternating and the fault alarm on the mattress had been turned off. The attention of the staff was drawn to this but it was not subsequently recorded in the deceased’s records. The staff were inadequately trained in pressure mattress management. They apparently checked that the mattress had a power source but did not check that the mattress was functioning correctly.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to identify staff completing care records
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to record declined interventions
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Unavailability of nursing staff for Tissue Viability Nurse calls
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to appreciate the importance of prescribed nutritional supplements
Wider context from the report “7. The deceased had lost a considerable amount of weight but there was no referral to a dietician (although the GP had been consulted regarding her weight loss and had prescribed supplements) The importance of the supplements was not fully appreciated by all of the staff. The deceased’s weight was maintained during a hospital stay but deteriorated on her return to New Park Nursing Home
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out pressure sore repositioning plans
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” 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 New Park Residential Home; that does not assign responsibility.
PFD Monitor interpretation Falsification of pressure sore repositioning records
Wider context from the report “1. The deceased had in place a management plan for dealing with her pressure sores. The plan was not adequately followed; turns were missed leaving long periods when the deceased remained unturned. Records were not appropriately kept when the deceased declined intervention. Records had been falsified and turns recorded when they had not been done. It was not possible to identify which member of staff had completed the forms. Nursing staff were not available to take calls from the Tissue Viability Nurses.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations