10 Jul 2024 Richard Michael Fitzgerald · Prevention of Future Deaths report East London
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Concerns raised 4 Failure to escalate inability to consistently follow the SALT care plan and obtain a contingency care plan View source Failure to incorporate the risk of picking up unsafe food into choking risk assessment and risk management planning View source Failure to follow the emergency protocol for choking View source Lack of thoroughness and professional curiosity in care home investigations View source See 1 more 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. 19
Action
Meet with all staff to share inquest findings and reinforce escalation and documentation of care concerns.
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Action
Use clinical review meetings to identify delivery difficulties and trigger re-referrals to relevant professionals.
View source
Action
Monitor adherence to care plans and refer behavioural barriers to external professionals for care-plan adaptation.
View source
Action
Allocate an additional ground-floor staff member during mealtimes to oversee high-risk residents’ safety.
View source
Action
Require at least two Board members to scrutinise completed significant-event investigations.
View source
Action
Ensure clinical leads, managers or qualified senior staff attend SALT assessments and reviews and promptly flag changes.
View source
Action
Allocate significant-event investigations to at least two independent investigators outside the involved care home.
View source
Action
Allocate staff to update identified risk assessments and require home-manager review, supported by quality and compliance audits.
View source
Action
Consider outsourcing significant-event investigations to an independent person outside the group when two senior managers are unavailable.
View source
Action
Review residents with swallowing difficulties and establish robust assessments capturing barriers to prescribed care.
View source
Action
Complete and regularly review choking risk assessments for all residents, including risks and barriers to prescribed care.
View source
Action
Display emergency-response posters throughout the building.
View source
Action
Reissue grab files to all units and regularly discuss their emergency guidance at team meetings.
View source
Action
Source coroners-inquest investigation training for the senior management team.
View source
Action
Hold fortnightly clinical reviews to identify high-risk residents, escalate concerns and notify relevant professional teams and funding authorities.
View source
Action
Develop and share a SALT register with the kitchen, including IDDIS levels.
View source
Action
Establish escalation guidance identifying relevant professionals, care-review involvement and risk-management planning when safe care is difficult to provide.
View source
Action
Hold regular emergency-response workshops to embed training and strengthen practical staff confidence.
View source
Action
Deliver first-aid, basic-life-support and choking emergency-response training to all staff.
View source See 16 more actions
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AI-generated summary
Richard Michael Fitzgerald · 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
Richard Michael Fitzgerald, a nursing home resident with Alzheimer’s dementia, died in hospital on 26 June 2023 after choking on food and suffering a catastrophic hypoxic brain injury. Concerns included the failure to develop and implement a sufficiently robust care plan addressing unsafe food access and supervision, failure to follow the emergency choking protocol, and an insufficiently thorough care home investigation.
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 Serencroft; that does not assign responsibility.
PFD Monitor interpretation Failure to escalate inability to consistently follow the SALT care plan and obtain a contingency care plan
Wider context from the report “1. The Care Home staff were aware that the SALT care plan could not be consistently followed in terms of close supervision , but did not discuss this with the SALT team to ensure that a contingency care plan could be put into 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 Serencroft; that does not assign responsibility.
PFD Monitor interpretation Failure to incorporate the risk of picking up unsafe food into choking risk assessment and risk management planning
Wider context from the report “2. The risk of Mr Fitzgerald picking up unsafe food was known to staff, but was not incorporated into the choking risk assessment and risk management plan .
” 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 Serencroft; that does not assign responsibility.
PFD Monitor interpretation Failure to follow the emergency protocol for choking
Wider context from the report “3. The emergency protocol for choking was not followed by the staff in attendance on 24 June 2023 (including qualified 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 Serencroft; that does not assign responsibility.
PFD Monitor interpretation Lack of thoroughness and professional curiosity in care home investigations
Wider context from the report “4. The Care Home’s investigation lacked thoroughness and professional curiosity .
” Open source report
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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 Meet with all staff to share inquest findings and reinforce escalation and documentation of care concerns.
Verbatim wording from the response “• Meetings are taking place with the whole staff team, to share the findings from the Inquest. These have been transparent and used as a learning opportunity for staff to understand, the importance of escalating concerns back to the practitioners that prescribed the resident’s care. These meetings will continue over the next couple of weeks, until all staff have been shared lessons learnt. We anticipate that we should have met with all the staff by the end of July ’24.” Source location Response from Serencroft
Open published response
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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 clinical review meetings to identify delivery difficulties and trigger re-referrals to relevant professionals.
Verbatim wording from the response “• Clinical review meetings that take place are specifically capturing any difficulties staff are experiencing in delivering safe, effective care and these will be triggered for a re-referral to the relevant professionals. This is an on-going piece of work.” Source location Response from Serencroft
Open published response
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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 Monitor adherence to care plans and refer behavioural barriers to external professionals for care-plan adaptation.
Verbatim wording from the response “4. Ensure that all care plans are being followed and monitoring this, ensuring that difficulties in following care plans due to Residents behaviours are fed back to external professionals so that these can be adapted to ensure the Residents are safe and their needs are being met.” Source location Response from Serencroft
Open published response
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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 Allocate an additional ground-floor staff member during mealtimes to oversee high-risk residents’ safety.
Verbatim wording from the response “3. An extra member of staff has been allocated to the ground floor; they will be present during mealtimes to oversee the safety of high-risk residents.” Source location Response from Serencroft
Open published response
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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 at least two Board members to scrutinise completed significant-event investigations.
Verbatim wording from the response “• Once a thorough investigation has been completed, this will be presented and further scrutinised by at least two members of the Board of Directors, to satisfy themselves that a thorough and robust investigation has taken place. This has been implemented immediately.” Source location Response from Serencroft
Open published response
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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 Ensure clinical leads, managers or qualified senior staff attend SALT assessments and reviews and promptly flag changes.
Verbatim wording from the response “• The Clinical lead / or home manager will ensure they are in attendance of any SALT assessments / reviews. If they are not available then it will always be a qualified nurse of senior carer that attends the review, to ensure any changes are flagged immediately to the SALT team.” Source location Response from Serencroft
Open published response
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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 Allocate significant-event investigations to at least two independent investigators outside the involved care home.
Verbatim wording from the response “• Following any significant events, the investigation will be allocated to at least two independent investigators, not from the Care Home involved in the incident. This has been implemented immediately.” Source location Response from Serencroft
Open published response
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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 Allocate staff to update identified risk assessments and require home-manager review, supported by quality and compliance audits.
Verbatim wording from the response “• Clinical review meetings will take place every 2 weeks that will identify all high-risk residents and if any risks are identified. The manager will then ensure, that they allocate the relevant staff member to update any risk assessments and that will be reviewed by the home manager.” Source location Response from Serencroft
Open published response
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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 Consider outsourcing significant-event investigations to an independent person outside the group when two senior managers are unavailable.
Verbatim wording from the response “• If there are not two Senior Managers available from the group, consideration will be given to outsource the investigation to an independent person not from our group. This has been implemented immediately.” Source location Response from Serencroft
Open published response
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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 Review residents with swallowing difficulties and establish robust assessments capturing barriers to prescribed care.
Verbatim wording from the response “• The Senior management team, alongside a specialist Independent Consultancy team have reviewed every resident care needs, with swallowing difficulties. They have ensured” Source location Response from Serencroft
Open published response
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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 regularly review choking risk assessments for all residents, including risks and barriers to prescribed care.
Verbatim wording from the response “6. Choking risk assessments have been completed on admission and reviewed monthly for all residents living at Gable Court, as well as when instructed to do so by external professionals or after incidents.” Source location Response from Serencroft
Open published response
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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 Display emergency-response posters throughout the building.
Verbatim wording from the response “• Visible posters are available for staff throughout the building.” Source location Response from Serencroft
Open published response
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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 Reissue grab files to all units and regularly discuss their emergency guidance at team meetings.
Verbatim wording from the response “5. Grab files have been re-issued to all the units.” Source location Response from Serencroft
Open published response
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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 Source coroners-inquest investigation training for the senior management team.
Verbatim wording from the response “• Training is being sourced for the Senior Management team on preparing for Coroners inquests, this will further support them in being more thorough in their investigation skills. This will be completed throughout September.” Source location Response from Serencroft
Open published response
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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 Hold fortnightly clinical reviews to identify high-risk residents, escalate concerns and notify relevant professional teams and funding authorities.
Verbatim wording from the response “• Clinical review meetings will take place every 2 weeks that will identify all high-risk residents and pick up on any barriers in delivering safe/ effective care. If any concerns are noted these will be escalated to the relevant professional team as well as the funding authority.” Source location Response from Serencroft
Open published response
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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 Develop and share a SALT register with the kitchen, including IDDIS levels.
Verbatim wording from the response “1. A SALT register has been developed and shared with kitchen, including all IDDIS Levels.” Source location Response from Serencroft
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 Establish escalation guidance identifying relevant professionals, care-review involvement and risk-management planning when safe care is difficult to provide.
Verbatim wording from the response “2. An Escalation to signpost the management team and leadership team at Gable Court, in particular if they are experiencing challenges with any resident in providing safe care. This includes which professionals should be contacted and involved in the residents care review. This also includes a risk management plan to support the home in minimising the risk of deterioration in the resident’s physical and mental wellbeing.” Source location Response from Serencroft
Open published response
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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 Hold regular emergency-response workshops to embed training and strengthen practical staff confidence.
Verbatim wording from the response “• Regular workshops will take place to further embed all the learning from the training that has been delivered; this will include how to deal with practical situations. This will further empower staff and give them more confidence in dealing with emergency situations.” Source location Response from Serencroft
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 first-aid, basic-life-support and choking emergency-response training to all staff.
Verbatim wording from the response “1. Further First aid including Basic life support training has been delivered in house to all staff.” Source location Response from Serencroft
Open published response
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations