Pelham House Residential Care Home with DementiaIncludes 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 8 Jun 2020•Latest report 8 Jun 2020

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 Pelham House Residential Care Home with Dementia linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Addressed to: Manager, Pelham House (Cedarcare (SE) Ltd).

    West Sussex

    AI-generated summary

    Mildred Horrex · 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

    Mildred Horrex suffered an unwitnessed fall while sleeping in a chair at Pelham House on 30 December 2017, sustaining fractures to her C1 and C2 vertebrae, and died in hospital on 18 January 2018. The concerns identified were poor and sometimes inaccurate record keeping, insufficient information for an adequate fall-risk assessment, and discrepancies between medication records and the amount of medication held that were not detected by audits.

    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 Pelham House Residential Care Home with Dementia; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate fall risk assessments

    Wider context from the report

    “1. During the course of the Inquest it was clear that overall the record keeping in respect of Mildred was poor. There was insufficient information taken about Mildred by the home before her admission to Pelham House, the information that was taken was at times inaccurate and this lead to an inadequate fall risk assessment being insufficient. ”
    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 Pelham House Residential Care Home with Dementia; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of monthly medication audits to detect recording discrepancies

    Wider context from the report

    “2. Whilst the drugs chart showed that Mildred was taking her medication regularly the amount of medication that was found after her death showed that this could not be the case. We were told that monthly drugs audits were apparently carried out but they did not pick up the discrepancies in the recording on the drugs charts and the amount of medication held. ”
    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 Pelham House Residential Care Home with Dementia; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate medication administration records

    Wider context from the report

    “2. Whilst the drugs chart showed that Mildred was taking her medication regularly the amount of medication that was found after her death showed that this could not be the case. We were told that monthly drugs audits were apparently carried out but they did not pick up the discrepancies in the recording on the drugs charts and the amount of medication held. ”
    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 Pelham House Residential Care Home with Dementia; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to obtain sufficient and accurate information before admission

    Wider context from the report

    “1. During the course of the Inquest it was clear that overall the record keeping in respect of Mildred was poor. There was insufficient information taken about Mildred by the home before her admission to Pelham House, the information that was taken was at times inaccurate and this lead to an inadequate fall risk assessment being insufficient. ”
    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