Concerns raised 12 Unclear documentation of falls, symptoms and measures taken to seek medical input View source Lack of policies for reporting concerns View source Inability of care home staff to meet residents’ care needs View source Failure to closely monitor medical conditions and follow escalation policies View source Failure to appropriately escalate concerns to Adult Social Care View source Failure to adequately manage and monitor breast infection View source Failure to carry out regular blood tests View source Unavailability of a system for actioning discharge summaries View source Lack of escalation policies View source Failure to document capacity appropriately in care plans View source Failure to record steps taken to support decision-making View source Lack of medication policies View source See 9 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 21
Action
Use wound and infection monitoring charts, including photographs, for structured documentation.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Stop accepting residents requiring one-to-one support under revised acceptance criteria.
Stated plannedThe respondent said that this action was planned when they made their response on 3 February 2026. View source
Action
Implement a clinical escalation protocol requiring early medical review when symptoms do not improve.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 February 2026. View source
Action
Use a documented escalation procedure to notify placing authorities when needs may exceed home capability.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Deliver refresher training on record keeping and documenting infection progression.
Stated plannedThe respondent said that this action was planned when they made their response on 3 February 2026. View source
Action
Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Have managers immediately review incident forms for detail, completeness and clinical appropriateness.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Disseminate admission and discharge documentation guidance to junior staff.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Scan all hospital discharge summaries directly into residents’ care plans on receipt.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Provide care staff refresher training in incident reporting and falls management.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Conduct daily management checks of notes for residents declining personal care or presenting clinical concerns.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Complete and consolidate operational policies covering medication, infection control, incidents, escalation, safeguarding, concerns and hospital discharge.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Remind staff to document and communicate concerns to Social Workers and Adult Social Care throughout residency.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Deliver further mental capacity and Mental Capacity Act training to trained staff.
Stated in progressThe respondent said that this action was in progress when they made their response on 3 February 2026. View source
Action
Strengthen falls management and post-incident observation procedures for documenting falls, assessments and escalation reasoning.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Use mandatory post-fall observation charts for unwitnessed or potentially injurious falls.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Require registered nurses to act on escalated concerns and update care plans.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Reinforce staff training in infection recognition, wound documentation, sepsis awareness and escalation.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Require multidisciplinary reviews when residents’ needs increase significantly.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Store operational policies centrally in a digital governance system accessible to all staff.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source
Action
Implement a formal mental capacity assessment procedure covering documentation, care-plan recording and best-interest processes.
Stated completedThe respondent said that this action was complete when they made their response on 3 February 2026. View source See 18 more actions
×
AI-generated summary
Pamela George · 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
Pamela George, aged 70, died at Derriford Hospital on 30 June 2023 after being urgently admitted with suspected sepsis. The report identified missed opportunities to carry out required blood tests, manage a breast infection, document and escalate a fall and medical concerns, assess and record capacity, and maintain relevant care-home policies and records.
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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Unclear documentation of falls, symptoms and measures taken to seek medical input
Wider context from the report “4. The documentation surrounding the fall, the symptoms seen and measures taken to seek medical input were not clear .
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of policies for reporting concerns
Wider context from the report “6. There was little or no evidence of policies in place generally at the home and in particular on medication, escalation and reporting of concerns .
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Inability of care home staff to meet residents’ care needs
Wider context from the report “3. It is likely that Miss George’s needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home’s ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen. The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss George being removed to another provider.
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to closely monitor medical conditions and follow escalation policies
Wider context from the report “3. It is likely that Miss George’s needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home’s ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen . The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss George being removed to another provider.
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to appropriately escalate concerns to Adult Social Care
Wider context from the report “3. It is likely that Miss George’s needs were too great for the care home and that the withdrawal of 1 to 1 supervision had an effect on the home’s ability to care for her. I do think it likely that she was unkempt because of the inability of staff to meet her needs as well as the sepsis This does not however remove the need for close monitoring of medical conditions and appropriate escalation policies to be followed and to happen. The home has been unable to provide me with evidence that they appropriately escalated concerns to Adult Social Care which may have resulted in additional care or Miss George being removed to another provider.
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately manage and monitor breast infection
Wider context from the report “2. The infection which caused her sepsis was a bacterial infection which ████████ told me could only have been successfully treated with antibiotics. I am not satisfied that the breast infection was adequately managed at Cann House it being noted that there was no record of how the breast infection was progressing between 25th May and 27th June 2023 .
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to carry out regular blood tests
Wider context from the report “1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed.
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a system for actioning discharge summaries
Wider context from the report “1. Cann House missed an opportunity to carry out regular blood tests on Miss George between 23rd May and 29th June. These blood tests may have identified the need to continue to treat acute kidney injury which if left untreated may have affected her resilience to infection. The system for ensuring that discharge summaries are actioned was not available for me to see and I was not clear if any policy on this issue existed .
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of escalation policies
Wider context from the report “6. There was little or no evidence of policies in place generally at the home and in particular on medication, escalation and reporting of concerns .
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to document capacity appropriately in care plans
Wider context from the report “5. There was little or no evidence that capacity had been appropriately documented with care plans remaining silent on the issue and records not analysing carefully what steps had been taken to help Miss George make decisions.
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to record steps taken to support decision-making
Wider context from the report “5. There was little or no evidence that capacity had been appropriately documented with care plans remaining silent on the issue and records not analysing carefully what steps had been taken to help Miss George make decisions .
” 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 Premiere Health Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of medication policies
Wider context from the report “6. There was little or no evidence of policies in place generally at the home and in particular on medication , escalation and reporting of concerns .
” Open source report
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use wound and infection monitoring charts, including photographs, for structured documentation.
Verbatim wording from the response “• Wound and Infection Monitoring Chart including documenting photographs is being used effectively to ensure clear, regular and structured documentation.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Stop accepting residents requiring one-to-one support under revised acceptance criteria.
Verbatim wording from the response “• Cann House Care Home has reviewed its acceptance criteria and will no longer accept residents requiring 1:1 support, recognising the significance of the challenges faced in Ms George’s case and wider systemic issues around funding.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a clinical escalation protocol requiring early medical review when symptoms do not improve.
Verbatim wording from the response “• A consolidated clinical escalation protocol is being implemented, requiring early medical review where symptoms do not improve.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use a documented escalation procedure to notify placing authorities when needs may exceed home capability.
Verbatim wording from the response “• A documented escalation procedure now mandates notification to the placing authority where needs may exceed home capability.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver refresher training on record keeping and documenting infection progression.
Verbatim wording from the response “• All staff will undertake refresher training on record keeping, including expectations for documenting infection progression.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Enforce the hospital discharge and clinical follow-up procedure, including review, action logging, GP confirmation and management audit.
Verbatim wording from the response “• The organisation has enforced its formal Hospital Discharge and Clinical Follow-Up Procedure, which includes:” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Have managers immediately review incident forms for detail, completeness and clinical appropriateness.
Verbatim wording from the response “• A new system has been implemented whereby a manager reviews all incident forms immediately following any incident to ensure detail, completeness and clinical appropriateness.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Disseminate admission and discharge documentation guidance to junior staff.
Verbatim wording from the response “• Information has been disseminated to all junior staff for awareness training, emphasising the importance of correctly processing admission and discharge documentation.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Scan all hospital discharge summaries directly into residents’ care plans on receipt.
Verbatim wording from the response “• All hospital discharge summaries are now scanned directly into residents’ care plans upon receipt.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Provide care staff refresher training in incident reporting and falls management.
Verbatim wording from the response “• All care staff have received refresher training in incident reporting and falls management.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Conduct daily management checks of notes for residents declining personal care or presenting clinical concerns.
Verbatim wording from the response “• The Care Manager now conducts daily checks on notes for residents who may be declining personal care or presenting clinical concerns.
○ In the Care Manager’s absence, this is undertaken by the Team Leader.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Complete and consolidate operational policies covering medication, infection control, incidents, escalation, safeguarding, concerns and hospital discharge.
Verbatim wording from the response “• A full review and consolidation of all operational policies has been completed.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Remind staff to document and communicate concerns to Social Workers and Adult Social Care throughout residency.
Verbatim wording from the response “• All staff have been reminded of the importance of documenting and communicating concerns to Social Workers and Adult Social Care, both at admission and throughout residency.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Deliver further mental capacity and Mental Capacity Act training to trained staff.
Verbatim wording from the response “• All trained staff are completing further mental capacity and MCA training, delivered in-house or via Plymouth City Council.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Strengthen falls management and post-incident observation procedures for documenting falls, assessments and escalation reasoning.
Verbatim wording from the response “• A strengthened Falls Management and Post-Incident Observation Procedures in place, including:
○ Comprehensive documentation of the fall circumstances.
○ Required physical observations and pain assessments.
○ Neurological observations where clinically indicated.
○ Clear documentation of clinical reasoning regarding escalation to medical professionals.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Use mandatory post-fall observation charts for unwitnessed or potentially injurious falls.
Verbatim wording from the response “• Mandatory post-fall observation charts are now used for unwitnessed or potentially injurious falls.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require registered nurses to act on escalated concerns and update care plans.
Verbatim wording from the response “• Registered Nurses are required to take action on concerns escalated to them and update care plans accordingly.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Reinforce staff training in infection recognition, wound documentation, sepsis awareness and escalation.
Verbatim wording from the response “• Staff training in infection recognition, wound documentation, sepsis awareness and escalation has been reinforced.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Require multidisciplinary reviews when residents’ needs increase significantly.
Verbatim wording from the response “• A requirement is in place for multidisciplinary reviews where needs increase significantly.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Store operational policies centrally in a digital governance system accessible to all staff.
Verbatim wording from the response “• Policies are now centrally stored within a digital governance system, accessible to all staff.” Source location Response from Cann House
Open published response
×
Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a formal mental capacity assessment procedure covering documentation, care-plan recording and best-interest processes.
Verbatim wording from the response “• A formal Mental Capacity Assessment Procedure is now in place requiring:” Source location Response from Cann House
Open published response
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations