Recipient

Orchard Care Homes

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First report 11 Sep 2015•Latest report 11 Sep 2015

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

Naming this recipient

Published responses
100%

Found for named reports

Concerns addressed
2

Across all linked responses

Stated actions
5

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.

100%published responses found
5stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

  1. Manchester West

    AI-generated summary

    Thomas Nicholls · 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

    Thomas Nicholls died in hospital on 14 April 2015 after recurrent vomiting, aspiration pneumonia and deterioration following PEG feeding, in the context of prior strokes and other illness. The substantive concerns included inadequate staff training in the mobility, handling and care of residents receiving PEG feeds, an unreported vomiting incident, inadequate recording of incidents, and malfunctioning bed equipment.

    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 Orchard Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of care-staff training and competence in PEG feeding, including resident mobility, handling and feed controls

    Wider context from the report

    “1. During the Inquest evidence was heard that i. On the 16th March 2015 Mr Nicholls’ daughter, ████████, visited Mr Nicholls at Arden Court to accompany Mr Nicholls to a hospital appointment. Mrs Mellor gave evidence that when she attended at 09.15hrs on that day her father was lay flat on the bed and it looked as if someone had been getting him ready for the hospital appointment but had been interrupted. Mrs Mellor knew that her father should not be laid flat whilst PEG feeding was in progress and she tried to find the remote control to adjust the angle of the bed without success. Mrs Mellor saw some feed in Mr Nicholls’ mouth and she gave evidence that he was violently sick with projectile vomiting. She asked a Carer about the angle of the bed and PEG feeding but the Carer informed Mrs Mellor that she had not been trained in PEG feeding. ii. It was clear from the evidence that care staff had indicated that they had not been trained in relation to PEG feeds, particularly in relation to mobility and handling of residents during PEG feeding and the incident on the 16th March 2015 had not been reported to the Manager of Arden Court, who had not considered either training or re-training in relation to PEG feeds. The Manager gave evidence at the Inquest that he was not aware of the incident on the 16th March 2015 until he heard the evidence at the Inquest and he had only become aware of the details of the incident during the course of the Inquest. He confirmed that there had been no review of training particularly in relation to mobility, handling and the care of residents on PEG feeding regimes. iii. Evidence was heard that residents may have to be laid flat at times whilst receiving PEG feed but there were controls to allow the feed to be placed on hold whilst mobilising and handling a resident. The care staff did not appear to be fully conversant with the controls of the PEG feed. iv. The remote control to operate the bed occupied by Mr Nicholls did not function due to the plug having been detached or the junction box having been smashed. v. The Manager was not aware of the incident on the 16th March 2015 and the incident did not appear to have been recorded so that any training needs in relation to staff, together with a review of risk assessments did not take place after the incident. vi. The evidence raised concerns that there is a risk that future deaths could occur unless action is taken to review the above issues. ”
    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 Orchard Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record and escalate incidents involving PEG feeding

    Wider context from the report

    “1. During the Inquest evidence was heard that i. On the 16th March 2015 Mr Nicholls’ daughter, ████████, visited Mr Nicholls at Arden Court to accompany Mr Nicholls to a hospital appointment. Mrs Mellor gave evidence that when she attended at 09.15hrs on that day her father was lay flat on the bed and it looked as if someone had been getting him ready for the hospital appointment but had been interrupted. Mrs Mellor knew that her father should not be laid flat whilst PEG feeding was in progress and she tried to find the remote control to adjust the angle of the bed without success. Mrs Mellor saw some feed in Mr Nicholls’ mouth and she gave evidence that he was violently sick with projectile vomiting. She asked a Carer about the angle of the bed and PEG feeding but the Carer informed Mrs Mellor that she had not been trained in PEG feeding. ii. It was clear from the evidence that care staff had indicated that they had not been trained in relation to PEG feeds, particularly in relation to mobility and handling of residents during PEG feeding and the incident on the 16th March 2015 had not been reported to the Manager of Arden Court, who had not considered either training or re-training in relation to PEG feeds. The Manager gave evidence at the Inquest that he was not aware of the incident on the 16th March 2015 until he heard the evidence at the Inquest and he had only become aware of the details of the incident during the course of the Inquest. He confirmed that there had been no review of training particularly in relation to mobility, handling and the care of residents on PEG feeding regimes. iii. Evidence was heard that residents may have to be laid flat at times whilst receiving PEG feed but there were controls to allow the feed to be placed on hold whilst mobilising and handling a resident. The care staff did not appear to be fully conversant with the controls of the PEG feed. iv. The remote control to operate the bed occupied by Mr Nicholls did not function due to the plug having been detached or the junction box having been smashed. v. The Manager was not aware of the incident on the 16th March 2015 and the incident did not appear to have been recorded so that any training needs in relation to staff, together with a review of risk assessments did not take place after the incident. vi. The evidence raised concerns that there is a risk that future deaths could occur unless action is taken to review the above issues. ”
    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 Orchard Care Homes; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the bed remote control needed to adjust the bed position during PEG feeding

    Wider context from the report

    “1. During the Inquest evidence was heard that i. On the 16th March 2015 Mr Nicholls’ daughter, ████████, visited Mr Nicholls at Arden Court to accompany Mr Nicholls to a hospital appointment. Mrs Mellor gave evidence that when she attended at 09.15hrs on that day her father was lay flat on the bed and it looked as if someone had been getting him ready for the hospital appointment but had been interrupted. Mrs Mellor knew that her father should not be laid flat whilst PEG feeding was in progress and she tried to find the remote control to adjust the angle of the bed without success. Mrs Mellor saw some feed in Mr Nicholls’ mouth and she gave evidence that he was violently sick with projectile vomiting. She asked a Carer about the angle of the bed and PEG feeding but the Carer informed Mrs Mellor that she had not been trained in PEG feeding. ii. It was clear from the evidence that care staff had indicated that they had not been trained in relation to PEG feeds, particularly in relation to mobility and handling of residents during PEG feeding and the incident on the 16th March 2015 had not been reported to the Manager of Arden Court, who had not considered either training or re-training in relation to PEG feeds. The Manager gave evidence at the Inquest that he was not aware of the incident on the 16th March 2015 until he heard the evidence at the Inquest and he had only become aware of the details of the incident during the course of the Inquest. He confirmed that there had been no review of training particularly in relation to mobility, handling and the care of residents on PEG feeding regimes. iii. Evidence was heard that residents may have to be laid flat at times whilst receiving PEG feed but there were controls to allow the feed to be placed on hold whilst mobilising and handling a resident. The care staff did not appear to be fully conversant with the controls of the PEG feed. iv. The remote control to operate the bed occupied by Mr Nicholls did not function due to the plug having been detached or the junction box having been smashed. v. The Manager was not aware of the incident on the 16th March 2015 and the incident did not appear to have been recorded so that any training needs in relation to staff, together with a review of risk assessments did not take place after the incident. vi. The evidence raised concerns that there is a risk that future deaths could occur unless action is taken to review the above issues. ”
    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

100%
100%All other recipients 58%
0%100%

How actions were described at the time

This respondent
100%
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