11 Jun 2025 Maureen POWELL · Prevention of Future Deaths report Nottinghamshire
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Concerns raised 12 Inaccurate reporting of incidents to regulators and social care View source Failure to retain key records View source Failure to update care plans regularly and when circumstances require View source Delays in providing an appropriate bed surface View source Incorrect adjustment of airflow mattresses View source Failure to conduct and record daily skin inspections View source Failure to keep family informed about wound deterioration View source Failure to undertake internal investigations View source Failure to consistently record repositioning View source Failure to consistently implement repositioning View source Lack of clear guidance to staff when pressure damage is identified View source Delays in referral to tissue viability services View source See 9 more concerns
Responses linked to these concerns
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AI-generated summary
Maureen POWELL · 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
Maureen Powell died from severe frailty after a prolonged period of ill health, hospitalisation and transfer to a nursing home. A serious pressure ulcer developed and worsened in the nursing home and contributed to her death. Concerns included inadequate recording and implementation of repositioning, failure to record skin inspections, delayed equipment and specialist referral, poor record-keeping, inaccurate reporting, and insufficient communication with her family.
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× 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Inaccurate reporting of incidents to regulators and social care
Wider context from the report “10. Inaccurate reports were made to the CQC and social care about the incidents ; and
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Failure to retain key records
Wider context from the report “9. Key records were not kept or were lost or destroyed ;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Failure to update care plans regularly and when circumstances require
Wider context from the report “3. Care plans were not updated regularly in line with good practice and were not always updated when the circumstances required ;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Delays in providing an appropriate bed surface
Wider context from the report “4. There was a delay in putting an appropriate bed surface in place ;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Incorrect adjustment of airflow mattresses
Wider context from the report “5. On at least one occasion the airflow mattress was incorrectly adjusted, reducing its efficacy ;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Failure to conduct and record daily skin inspections
Wider context from the report “2. There was widespread non-compliance with the regime of daily skin inspections in the period of time that Maureen was a resident at the Nursing Home. Not one skin inspection was recorded during Maureen’s stay ;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Failure to keep family informed about wound deterioration
Wider context from the report “6. The family were not kept up to date about deterioration in the wound ;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake internal investigations
Wider context from the report “8. No internal investigation was undertaken ;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently record repositioning
Wider context from the report “1. Repositioning was undertaken, but recording and implementation was, at times, patchy;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Failure to consistently implement repositioning
Wider context from the report “1. Repositioning was undertaken, but recording and implementation was, at times, patchy ;
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Lack of clear guidance to staff when pressure damage is identified
Wider context from the report “11. There was an apparent lack of clear guidance to staff as to what to do if or when pressure damage was identified .
” 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 Red Oaks Care Community; that does not assign responsibility.
PFD Monitor interpretation Delays in referral to tissue viability services
Wider context from the report “7. The referral to tissue viability was made too late as it occurred after the wound had got beyond the ability of the in-house nursing staff to manage and treat the wound ;
” 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