Recipient

Serencroft

First report 10 Jul 2024•Latest report 10 Jul 2024

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Care-home operator. 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: 29

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

29stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

10 Jul2024
East London
Concerns raised4
1. Failure to escalate inability to consistently follow the SALT care plan and obtain a contingency care plan
2. Failure to incorporate the risk of picking up unsafe food into choking risk assessment and risk management planning
3. Failure to follow the emergency protocol for choking
1. Lack of thoroughness and professional curiosity in care home investigations
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 19
1. Action
  Meet with all staff to share inquest findings and reinforce escalation and documentation of care concerns.
  Stated in progress
2. Action
  Use clinical review meetings to identify delivery difficulties and trigger re-referrals to relevant professionals.
  Stated in progress
3. Action
  Monitor adherence to care plans and refer behavioural barriers to external professionals for care-plan adaptation.
  Stated in progress
1. Action
  Allocate an additional ground-floor staff member during mealtimes to oversee high-risk residents’ safety.
  Stated completed
2. Action
  Require at least two Board members to scrutinise completed significant-event investigations.
  Stated completed
3. Action
  Ensure clinical leads, managers or qualified senior staff attend SALT assessments and reviews and promptly flag changes.
  Stated in progress
4. Action
  Allocate significant-event investigations to at least two independent investigators outside the involved care home.
  Stated completed
5. Action
  Allocate staff to update identified risk assessments and require home-manager review, supported by quality and compliance audits.
  Stated planned
6. Action
  Consider outsourcing significant-event investigations to an independent person outside the group when two senior managers are unavailable.
  Stated completed
7. Action
  Review residents with swallowing difficulties and establish robust assessments capturing barriers to prescribed care.
  Stated completed
8. Action
  Complete and regularly review choking risk assessments for all residents, including risks and barriers to prescribed care.
  Stated completed
9. Action
  Display emergency-response posters throughout the building.
  Stated completed
10. Action
  Reissue grab files to all units and regularly discuss their emergency guidance at team meetings.
  Stated completed
11. Action
  Source coroners-inquest investigation training for the senior management team.
  Stated in progress
12. Action
  Hold fortnightly clinical reviews to identify high-risk residents, escalate concerns and notify relevant professional teams and funding authorities.
  Stated planned
13. Action
  Develop and share a SALT register with the kitchen, including IDDIS levels.
  Stated completed
14. Action
  Establish escalation guidance identifying relevant professionals, care-review involvement and risk-management planning when safe care is difficult to provide.
  Stated completed
15. Action
  Hold regular emergency-response workshops to embed training and strengthen practical staff confidence.
  Stated planned
16. Action
  Deliver first-aid, basic-life-support and choking emergency-response training to all staff.
  Stated completed
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
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
Page 3 · response
Published 30 July 2024
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
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
Page 3 · response
Published 30 July 2024
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
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
Page 2 · response
Published 30 July 2024
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
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
Page 2 · response
Published 30 July 2024
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
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
Page 5 · response
Published 30 July 2024
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
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
Page 3 · response
Published 30 July 2024
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
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
Page 5 · response
Published 30 July 2024
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
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
Page 3 · response
Published 30 July 2024
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
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
Page 5 · response
Published 30 July 2024
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
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
Page 2 · response
Published 30 July 2024
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
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
Page 2 · response
Published 30 July 2024
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
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
Page 4 · response
Published 30 July 2024
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
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
Page 2 · response
Published 30 July 2024
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
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
Page 5 · response
Published 30 July 2024
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
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
Page 3 · response
Published 30 July 2024
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
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
Page 2 · response
Published 30 July 2024
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
Page 2 · response
Published 30 July 2024
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
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
Page 4 · response
Published 30 July 2024
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
Page 1 · response
Published 30 July 2024
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 escalate inability to consistently follow the SALT care plan and obtain a contingency care plan

Failure to incorporate the risk of picking up unsafe food into choking risk assessment and risk management planning

Failure to follow the emergency protocol for choking

Lack of thoroughness and professional curiosity in care home investigations

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

Actions described in response 19