Recipient

Oak Court House

First report 3 Apr 2020•Latest report 3 Apr 2020

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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

3 Apr2020
Black Country
Concerns raised13
1. Failure of home manager follow-up checks after deterioration
2. Failure to document increased observation arrangements in written records or care plans
3. Failure to record or report resident deterioration and drowsiness
1. Failure to record resident bedroom-door status
2. Failure to undertake violence risk assessments after admission or incidents
3. Lack of alternative arrangements enabling residents with disabilities to call for assistance from their rooms
4. Failure to record instructions for ongoing checks and escalation
5. Failure to record the timing and findings of resident observations
6. Lack of information on admission of new residents
7. Lack of a clear head-injury management policy
8. Failure to include resident bedroom-door preferences in care plans
9. Delays in seeking medical review after head injury
10. Failure to provide and adjust neurological observations after head injury
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.
AI-generated summary

Edna May Davenport · 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

Edna May Davenport, a resident of Oak Court House residential care home, sustained head injuries during an unwitnessed assault by another resident and died in hospital on 12 December 2019. The report raised concerns about the removal of her alarm without documented alternative arrangements, inadequate recording and monitoring of observations, insufficient risk assessment of the other resident, and delays in responding to signs of head injury and deterioration.

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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure of home manager follow-up checks after deterioration
Wider context from the report
“(7) No further checks were carried out by the home manager after this time and it appeared that evidence of the deceased becoming unwell and suffering with episodes of drowsiness were not recorded or indeed reported by staff caring for her. I am concerned that Oak Court does not have a clear policy in place to manage head injuries; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure to document increased observation arrangements in written records or care plans
Wider context from the report
“(1) During the course of the inquest, I heard evidence that buzzer/alarm in the deceased room had been removed/disabled due to a previous incident where the deceased had attempted to place the cord around her neck. The family were told that as a result, observations of the deceased had been increased to every 15 minutes day and night. There was no evidence of this in any written records or care plan and no evidence of alternative arrangements in her care plan being made to enable the deceased to call for assistance from her room should it be needed given her disabilities; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure to record or report resident deterioration and drowsiness
Wider context from the report
“(7) No further checks were carried out by the home manager after this time and it appeared that evidence of the deceased becoming unwell and suffering with episodes of drowsiness were not recorded or indeed reported by staff caring for her. I am concerned that Oak Court does not have a clear policy in place to manage head injuries; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure to record resident bedroom-door status
Wider context from the report
“(3) I also heard in evidence that the deceased preferred to have her bedroom door left open but this did not form part of her care plan and there was no evidence as to when the door was in fact left open, or when it was closed, or indeed whether the door was open when the other resident was found in the deceased’s room; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure to undertake violence risk assessments after admission or incidents
Wider context from the report
“(4) I heard evidence during the inquest that the other resident suspected to have been the assailant was a new referral to the home and that there was a lack of information on her admission. The evidence at inquest was that staff were unaware that she was aggressive as a result of her vascular dementia. There was some evidence identified during the police investigation that this resident had attacked a member of staff shortly after her admission and that she had been inappropriately placed at Oak Court house. There was no evidence that any risk assessment had been undertaken after that resident’s admission or after the first alleged attack to address the risk of violence that the resident posed to others by virtue of the extent of her dementia; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Lack of alternative arrangements enabling residents with disabilities to call for assistance from their rooms
Wider context from the report
“(1) During the course of the inquest, I heard evidence that buzzer/alarm in the deceased room had been removed/disabled due to a previous incident where the deceased had attempted to place the cord around her neck. The family were told that as a result, observations of the deceased had been increased to every 15 minutes day and night. There was no evidence of this in any written records or care plan and no evidence of alternative arrangements in her care plan being made to enable the deceased to call for assistance from her room should it be needed given her disabilities; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure to record instructions for ongoing checks and escalation
Wider context from the report
“(6) The evidence was that staff had been informed by the Manager to continue carrying out hourly checks and to call an ambulance if there was any change but there was no evidence of this in any of the deceased’s records or daily notes; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure to record the timing and findings of resident observations
Wider context from the report
“(2) I heard evidence that the deceased was subject to hourly observations but that these observations were not recorded as to when they actually took place or what was observed. Therefore, it was not possible to ascertain how long the other resident had been in the room with the deceased or how long the assault went on for; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Lack of information on admission of new residents
Wider context from the report
“(4) I heard evidence during the inquest that the other resident suspected to have been the assailant was a new referral to the home and that there was a lack of information on her admission. The evidence at inquest was that staff were unaware that she was aggressive as a result of her vascular dementia. There was some evidence identified during the police investigation that this resident had attacked a member of staff shortly after her admission and that she had been inappropriately placed at Oak Court house. There was no evidence that any risk assessment had been undertaken after that resident’s admission or after the first alleged attack to address the risk of violence that the resident posed to others by virtue of the extent of her dementia; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Lack of a clear head-injury management policy
Wider context from the report
“(7) No further checks were carried out by the home manager after this time and it appeared that evidence of the deceased becoming unwell and suffering with episodes of drowsiness were not recorded or indeed reported by staff caring for her. I am concerned that Oak Court does not have a clear policy in place to manage head injuries; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure to include resident bedroom-door preferences in care plans
Wider context from the report
“(3) I also heard in evidence that the deceased preferred to have her bedroom door left open but this did not form part of her care plan and there was no evidence as to when the door was in fact left open, or when it was closed, or indeed whether the door was open when the other resident was found in the deceased’s room; ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Delays in seeking medical review after head injury
Wider context from the report
“(8) The deceased was an elderly lady who had suffered a head injury and was known to be anti-coagulant medication, yet no medical review was sought until an ambulance was called on 29/11/19 when the deceased became unresponsive. A concern was raised by hospital staff on her admission and a safe guarding referral was made. ”
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 Oak Court House; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide and adjust neurological observations after head injury
Wider context from the report
“(5) I heard evidence that there were obvious signs of an injury to Edna’s head in the form of the injury to her eye which resulted in bruising and swelling. There was also evidence that the deceased had been punched to the head. The District Nurse recorded that Edna had had a headache and the deceased had complained to her daughter about suffering with a headache shortly after the assault. Despite this, no neuro observations were undertaken and there was no change to the frequency of Edna’s observations; ”
Open source report

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

Reports, concerns and published responses

Reports over time

Concerns raised13

Failure of home manager follow-up checks after deterioration

Failure to document increased observation arrangements in written records or care plans

Failure to record or report resident deterioration and drowsiness

Failure to record resident bedroom-door status

Failure to undertake violence risk assessments after admission or incidents

Lack of alternative arrangements enabling residents with disabilities to call for assistance from their rooms

Failure to record instructions for ongoing checks and escalation

Failure to record the timing and findings of resident observations

Lack of information on admission of new residents

Lack of a clear head-injury management policy

Failure to include resident bedroom-door preferences in care plans

Delays in seeking medical review after head injury

Failure to provide and adjust neurological observations after head injury