31 Oct 2025 Gloria SIMON · Prevention of Future Deaths report Liverpool and the Wirral
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Concerns raised 6 Failure to act appropriately on basic observation results View source Failure to take basic observations when clinically indicated View source Inadequate recording of basic observation results View source Failure to obtain timely alternative clinical input when the registered GP is unavailable View source Failure to accurately identify the care setting and available clinical staff in requests for care View source Insufficient training of non-clinical staff in responding to urgent health concerns View source See 3 more concerns
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Gloria SIMON · 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
Gloria Simon moved into a care home for respite care and died there from natural causes on 20 September 2025 after her health deteriorated. Concerns included missed opportunities for timely clinical assistance, a GP misunderstanding the care home setting and oxygen saturation reading, and possible insufficient training of non-clinical staff in seeking help and taking and responding to basic observations.
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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 Riversdale Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to act appropriately on basic observation results
Wider context from the report “3. It was not clear from the evidence that the staff at the care home have been trained so that they have a sufficient understanding of when basic observations should be taken, how and where the results should be recorded or how they should be acted upon.
There was no evidence that observations has been carried out prior to 19 January, despite Gloria Simon having been judged sufficiently unwell on 17 January that a GP should be called. The court was not made aware of when the observation results contained in the Request for Care form had been taken, nor whether further observations were taken at all in the period of more than 24 hours between then and her death.
The court is concerned that the training received by care home staff did not enable them to understand the potential value and importance of basic observations, nor to understand how they should act upon them , thereby denying them (and clinicians who might be involved later) information which might assist in determining the seriousness and evolving nature of the condition of an elderly and vulnerable resident . The court would like to know what measures are being taken to address this.
” 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 Riversdale Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to take basic observations when clinically indicated
Wider context from the report “3. It was not clear from the evidence that the staff at the care home have been trained so that they have a sufficient understanding of when basic observations should be taken , how and where the results should be recorded or how they should be acted upon.
There was no evidence that observations has been carried out prior to 19 January , despite Gloria Simon having been judged sufficiently unwell on 17 January that a GP should be called. The court was not made aware of when the observation results contained in the Request for Care form had been taken, nor whether further observations were taken at all in the period of more than 24 hours between then and her death.
The court is concerned that the training received by care home staff did not enable them to understand the potential value and importance of basic observations, nor to understand how they should act upon them, thereby denying them (and clinicians who might be involved later) information which might assist in determining the seriousness and evolving nature of the condition of an elderly and vulnerable resident. The court would like to know what measures are being taken to address this.
” 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 Riversdale Care Home; that does not assign responsibility.
PFD Monitor interpretation Inadequate recording of basic observation results
Wider context from the report “3. It was not clear from the evidence that the staff at the care home have been trained so that they have a sufficient understanding of when basic observations should be taken, how and where the results should be recorded or how they should be acted upon.
There was no evidence that observations has been carried out prior to 19 January, despite Gloria Simon having been judged sufficiently unwell on 17 January that a GP should be called. The court was not made aware of when the observation results contained in the Request for Care form had been taken, nor whether further observations were taken at all in the period of more than 24 hours between then and her death .
The court is concerned that the training received by care home staff did not enable them to understand the potential value and importance of basic observations, nor to understand how they should act upon them, thereby denying them (and clinicians who might be involved later) information which might assist in determining the seriousness and evolving nature of the condition of an elderly and vulnerable resident. The court would like to know what measures are being taken to address this.
” 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 Riversdale Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain timely alternative clinical input when the registered GP is unavailable
Wider context from the report “2. On 17 September 2025 the staff at the care home were sufficiently concerned about the Gloria Simon’s health that they sought assistance from her registered GP, who declined to visit because she was no longer within their area. Whilst efforts were made to register her with a practice local to the care home, staff did not make any alternative arrangements for obtaining clinical input in the meantime . The court heard that staff should have called 111. Depending upon the seriousness of their concerns, another possibility would have been to call 999. In fact, no further attempt was made to seek help until 14:52 on 19 September 2025 .
The court is concerned that the training of non-clinical staff was insufficient to equip them with knowledge about how to manage a situation such as this effectively and would like to know what measures are being taken to address this.
” 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 Riversdale Care Home; that does not assign responsibility.
PFD Monitor interpretation Failure to accurately identify the care setting and available clinical staff in requests for care
Wider context from the report “1. The email sent to the GP practice with the ‘Request for Care’ form noted the sender’s email address to be ████████ (RIVERSDALE NURSING HOME, WIRRAL). On the form itself, the box in which the sender was asked to identify the staff involved in the case was completed with the words ‘Riversdale Nursing Home’, which was its name before it changed from a nursing home to a care home in 2023.
The GP to whom the request was passed for action told the court that he believed that the Gloria Simon was resident in a nursing home setting , and that he would have acted differently (by making a visit to see her in person) if he had known that it was in fact a care home setting, with no clinically qualified staff members on site .
The court is concerned that this preventable misunderstanding contributed to a vulnerable elderly resident being left without a face-to-face clinical assessment (which would have been likely to result in a different approach to care and management) and would like to know what measures are being taken to address this.
” 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 Riversdale Care Home; that does not assign responsibility.
PFD Monitor interpretation Insufficient training of non-clinical staff in responding to urgent health concerns
Wider context from the report “2. On 17 September 2025 the staff at the care home were sufficiently concerned about the Gloria Simon’s health that they sought assistance from her registered GP, who declined to visit because she was no longer within their area. Whilst efforts were made to register her with a practice local to the care home, staff did not make any alternative arrangements for obtaining clinical input in the meantime. The court heard that staff should have called 111. Depending upon the seriousness of their concerns, another possibility would have been to call 999. In fact, no further attempt was made to seek help until 14:52 on 19 September 2025.
The court is concerned that the training of non-clinical staff was insufficient to equip them with knowledge about how to manage a situation such as this effectively and would like to know what measures are being taken to address this.
” 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