Recipient

Rossmere Park Care Centre

First report 28 May 2019•Latest report 28 May 2019

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing home. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 4
Stated actions: 6

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.

100%published responses found

6stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Rossmere Park Care Centre linked to the concerns in each report. Select any concern, action or position to view the source wording.

28 May2019
Teesside and Hartlepool
Concerns raised4
1. Failure to provide first aid and airway-clearing assistance during choking
2. Failure to remedy identified safety issues
3. Failure to investigate choking-related events and identify safety issues
1. Lack of clarity about the existence of a DNA CPR
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Submit a safeguarding alert to Hartlepool Social Services for further investigation.
  Stated completed
2. Action
  Implement a protocol for staff to follow after a resident’s death.
  Stated completed
3. Action
  Implement a DNACPR notification system using door markers and prominent notices in residents’ room folders.
  Stated completed
1. Action
  Participate in lessons-learned meetings with safeguarding, commissioning, healthcare and police representatives.
  Stated completed
2. Action
  Produce a more user-friendly Choking Risk Assessment in consultation with the SALT team.
  Stated completed
Respondent positions 2
1. Position
  The first HCA did not discover choking; there were no choking signs, and subsequent airway checks found no obstruction.
  Disputes the concern
1. Position
  A separate internal investigation was considered inappropriate while CQC had been notified and the Coroner was conducting a full investigation.
  Existing arrangements considered sufficient
AI-generated summary

Gloria Elizabeth MEKINS · 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 Elizabeth Mekins was a resident at Rossmere Park Care Home when she choked while eating a snack on 2 October 2018 and died at the care home. Concerns included the absence of first aid by the staff member who found her, confusion about the existence of a DNA CPR leading to a delay in first aid, and the care home's failure to investigate or address these issues.

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 Rossmere Park Care Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide first aid and airway-clearing assistance during choking
Wider context from the report
“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”
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 Rossmere Park Care Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to remedy identified safety issues
Wider context from the report
“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”
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 Rossmere Park Care Centre; that does not assign responsibility.
PFD Monitor interpretation
Failure to investigate choking-related events and identify safety issues
Wider context from the report
“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”
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 Rossmere Park Care Centre; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity about the existence of a DNA CPR
Wider context from the report
“(1) The Health Care Assistant who initially discovered Ms Mekins choking carried out no first aid, nor did she take any action to try to clear Ms Mekins' mouth or help improve her breathing, eg back slaps or Heimlich manoeuvre. (2) There was confusion as to the existence of a DNA CPR and this led to a delay in the provision of first aid. (3) The Care Home had not undertaken an internal investigation into events surrounding Ms Mekins' death and have not identified the above issues, nor have they attempted to remedy them. The Senior Coroner is concerned that the above issues place residents at the Care Home at risk of serious injury or death. ”
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
Submit a safeguarding alert to Hartlepool Social Services for further investigation.

Verbatim wording from the response
“However, it became apparent at the end of November that further investigation was required and I submitted a Safeguarding Alert to Hartlepool Social Services on 3.12.2018.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019
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 protocol for staff to follow after a resident’s death.

Verbatim wording from the response
“The CCG suggested we draft a Protocol for staff to follow after a death (sudden or otherwise) and we implemented this immediately following the Lessons Learned Meeting. The CCG also suggested that we draft a form where the home could document any concerns identified as risks associated with a resident’s decisions and advice to mitigate those risks.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019
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 DNACPR notification system using door markers and prominent notices in residents’ room folders.

Verbatim wording from the response
“Staff are advised which resident has a DNACPR Notice by means of a whiteboard within the Nurse’s office at Rossmere Park Care Centre – with the same facility in the Senior’s office on the Ground Floor. This shows against each resident’s room, whether a DNACPR is in place and the date it expires. The Daily Handover sheets also show clearly against each room which resident has a DNACPR.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 2 · response
Published 2 August 2019
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
Participate in lessons-learned meetings with safeguarding, commissioning, healthcare and police representatives.

Verbatim wording from the response
“I attended a Lessons Learned Meeting on 8th. January 2019, at which both Hartlepool’s Safeguarding and Commissioning Teams, a representative from the CCG (NHS) and the Police were present.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019
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
Produce a more user-friendly Choking Risk Assessment in consultation with the SALT team.

Verbatim wording from the response
“It was also apparent from my e-mails with your office that the Choking Risk Assessment used by Rossmere was not easily understood. We therefore liaised in depth with the”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
The first HCA did not discover choking; there were no choking signs, and subsequent airway checks found no obstruction.

Verbatim wording from the response
“Although I have addressed your Matters of Concern below, the first point I must make is that your assertion in point 4 – Circumstances of Death – that “staff attended and believed she was choking” is incorrect as there is no evidence in any of the staff statements (which were written soon after the event) that ANY staff believed she was choking at the time of the incident.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 1 · response
Published 2 August 2019
Open published response
Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation
A separate internal investigation was considered inappropriate while CQC had been notified and the Coroner was conducting a full investigation.

Verbatim wording from the response
“In line with CQC requirements, I submitted a Notification 16 (Death of a Resident) to CQC on 2nd October 2018 before I went on leave.”

Source location
2019-0171-Response-by-Rossmere-Park-Care-Centre
Page 3 · response
Published 2 August 2019
Open published response

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 raised4

Failure to provide first aid and airway-clearing assistance during choking

Failure to remedy identified safety issues

Failure to investigate choking-related events and identify safety issues

Lack of clarity about the existence of a DNA CPR

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.5

Respondent positions A position is what this recipient says about the concern when it does not describe a specific action.2

Actions described in response 5

Respondent positions 2