Recipient

Recipient name withheld

First report 13 Sep 2022•Latest report 13 Sep 2022

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 Recipient name withheld linked to the concerns in each report. Select any concern, action or position to view the source wording.

13 Sep2022
Worcestershire
Concerns raised11
1. Delays in calling an ambulance when a resident’s condition requires emergency assistance
2. Failure to maintain records of medications dispensed to residents
3. Failure to record required twice-daily oral-cavity checks
1. Ineffective investigation of resident deaths
2. Failure to ensure effective supervision of nursing staff
3. Failure to materially improve senior management oversight of the Registered Manager and deputy manager
4. Failure to improve record keeping and record retention
5. Failure to provide accurate and comprehensive audit information
6. Shortcomings in senior management oversight of the Registered Manager
7. Failure to ensure that all medications are recorded
8. Failure to complete nursing records of residents’ medical conditions
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

Mr Peter Antony Joseph Pearson · 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

Mr Peter Antony Joseph Pearson died at Worcester Royal Hospital on 6 December 2021 from aspiration pneumonia, which was in all probability acquired while he was resident at Corbett House Nursing Home. Concerns included a delay in calling an ambulance despite his critical condition, incomplete nursing and medication records, failures in oral-cavity checks, shortcomings in management oversight, and an ineffective investigation into his death.

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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Delays in calling an ambulance when a resident’s condition requires emergency assistance
Wider context from the report
“(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to maintain records of medications dispensed to residents
Wider context from the report
“(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to record required twice-daily oral-cavity checks
Wider context from the report
“(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Ineffective investigation of resident deaths
Wider context from the report
“(3) It is accepted on behalf of the Home that there was an “ineffective investigation” into Mr Pearson’s death by the Home. Responsibility for that cannot not solely be attributed to the former Registered Manager. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure effective supervision of nursing staff
Wider context from the report
“(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to materially improve senior management oversight of the Registered Manager and deputy manager
Wider context from the report
“(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to improve record keeping and record retention
Wider context from the report
“(4) Whilst there have been changes to audit practice, including the use of an external auditor it is not apparent that the oversight by senior management of the Registered Manager or DM has changed materially. Nor is it apparent what the current Registered Manager has done to date to improve record keeping and record retention and the supervision of nursing staff. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide accurate and comprehensive audit information
Wider context from the report
“(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection”. It is accepted by senior management that there were “shortcomings” in oversight of this manager. The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Shortcomings in senior management oversight of the Registered Manager
Wider context from the report
“(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection”. It is accepted by senior management that there were “shortcomings” in oversight of this manager. The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to ensure that all medications are recorded
Wider context from the report
“(2) The former Registered Manager of the home at the time of the death is said by the Home’s owner, to be responsible for shortcomings in the management of the home including “providing false audit scores to senior management and cherry picking files which were presented for inspection”. It is accepted by senior management that there were “shortcomings” in oversight of this manager. The deputy manager (“DM”) at the time of Mr Pearson’s death has now been promoted to Registered Manager despite the fact that her job description as DM include responsibility for supervising and managing staff and ensuring that all medications were recorded. ”
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 Recipient name withheld; that does not assign responsibility.
PFD Monitor interpretation
Failure to complete nursing records of residents’ medical conditions
Wider context from the report
“(1) Mr Pearson’s condition on 5 December 2021 was such that his daughter asked the agency nurse on duty for an ambulance to be called at 12.30 pm. None was called until 6.10 pm. The nurse did not complete the nursing notes for the day from 5am onwards so there is no written record of Mr Pearson’s medical condition that day. Mr Pearson was found by paramedics alone in his room in a critical state. The staff on duty knew very little about him or his condition. No record of medications dispensed to Mr Pearson that day has been lost or is missing. He was found with medication in his mouth by paramedics. No records were kept of the checks of his oral cavity that were required to be undertaken twice a day. The Agency nurse has not been traced by the Home. The inquest found as a fact that the failure to call an ambulance earlier amounted to a missed opportunity. ”
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 raised11

Delays in calling an ambulance when a resident’s condition requires emergency assistance

Failure to maintain records of medications dispensed to residents

Failure to record required twice-daily oral-cavity checks

Ineffective investigation of resident deaths

Failure to ensure effective supervision of nursing staff

Failure to materially improve senior management oversight of the Registered Manager and deputy manager

Failure to improve record keeping and record retention

Failure to provide accurate and comprehensive audit information

Shortcomings in senior management oversight of the Registered Manager

Failure to ensure that all medications are recorded

Failure to complete nursing records of residents’ medical conditions