Oak Tree MewsIncludes reports addressed to a minister or senior office-holder acting for this organisation.

Private and voluntary organisations · Residential care home

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First report 12 Aug 2025•Latest report 12 Aug 2025

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

  1. Addressed to: Manager, Oak Tree Mews Care Home.

    Gloucestershire

    AI-generated summary

    Margaret Taylor · 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

    Margaret Taylor, who had dementia, dysphagia and a severe risk of choking, died after choking on chicken brought to her care home on 8 November 2024. Concerns included her removal from a soft-food diet without a documented rationale or further SALT assessment, and staff not checking food brought in by her husband for suitability in accordance with the home's policy.

    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 Tree Mews; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to document the rationale for important SALT-related decisions

    Wider context from the report

    “- There was no documented rationale, or further SALT assessment, before Maggie was removed from the soft food diet - Food brought in by Maggie’s husband was not checked for suitability by the staff at the home I am concerned that if important decisions are being taken without proper assessment by the SALT team, and the rationale for these decisions is not being properly documented, and if food is not being check in accordance with policy, then there is a risk of future deaths. ”
    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 Tree Mews; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain further SALT assessment before changing a soft food diet

    Wider context from the report

    “- There was no documented rationale, or further SALT assessment, before Maggie was removed from the soft food diet - Food brought in by Maggie’s husband was not checked for suitability by the staff at the home I am concerned that if important decisions are being taken without proper assessment by the SALT team, and the rationale for these decisions is not being properly documented, and if food is not being check in accordance with policy, then there is a risk of future deaths. ”
    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 Tree Mews; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to check food brought into the home for suitability

    Wider context from the report

    “- There was no documented rationale, or further SALT assessment, before Maggie was removed from the soft food diet - Food brought in by Maggie’s husband was not checked for suitability by the staff at the home I am concerned that if important decisions are being taken without proper assessment by the SALT team, and the rationale for these decisions is not being properly documented, and if food is not being check in accordance with policy, then there is a risk of future deaths. ”
    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

Data last updated 7 September 2026