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First report 27 Dec 2018•Latest report 27 Dec 2018

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

Concerns and recipient responses

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

27 Dec2018
Manchester South
Concerns raised8
1. Lack of statutory minimum requirements for lift servicing
2. Lack of a care home system for reviewing and passing lift examination details to the servicing company
3. Lack of formal minimum qualification standards for lift engineers
1. Lack of clarity about informing engineers of and following up regulatory lift examination requirements
2. Electronic lift servicing appointment systems lacking checklists
3. Failure of home inspections to identify unacted-on regulatory lift examination faults
4. Failure to read, act on, and escalate regulatory lift examination findings
5. Failure to require lift servicing and repair engineers to obtain regulatory examination reports
No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Kenneth Roy Bardsley · 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

Kenneth Roy Bardsley died at Salford Royal Hospital on 30 January 2017 from multiple injuries sustained as a passenger in a lift that malfunctioned at Serendipity Care Home. The inquest concluded that his accidental death was contributed to by failure of the lift’s interior door mechanism. Concerns included gaps in lift-engineer qualification requirements, failures to read and act on regulatory examination findings, unclear communication and follow-up processes, and insufficient systems for lift servicing and examination records.

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 Serendipity Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of statutory minimum requirements for lift servicing
Wider context from the report
“7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist. One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift service. ”
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 Serendipity Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of a care home system for reviewing and passing lift examination details to the servicing company
Wider context from the report
“5. That Serendipity Care Home did not have a system in place to ensure details from the lift examinations were read; considered and passed on to the lift servicing company; ”
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 Serendipity Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of formal minimum qualification standards for lift engineers
Wider context from the report
“1. The inquest heard that there are no formal requirements for a minimum standard of qualification for people to be lift engineers. In effect, anyone can advertise themselves as a lift engineer/maintenance company; ”
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 Serendipity Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity about informing engineers of and following up regulatory lift examination requirements
Wider context from the report
“3. During the inquest evidence was given that within the specific lift company in this case and more widely, there was a lack of clarity as to how engineers should be made aware and follow up requirements made by engineers carrying out the regulatory lift examinations; ”
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 Serendipity Home; that does not assign responsibility.
PFD Monitor interpretation
Electronic lift servicing appointment systems lacking checklists
Wider context from the report
“7. That the lift company Lancs and Cumbria Lifts had abandoned their old paper checklists and introduced an electronic appointment system. However that system did not include an electronic checklist. One had now been introduced. It was unclear if other companies have checklists and if so how consistent are they. The inquest heard that there was no statutory minimum expectation about the requirements of a lift service. ”
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 Serendipity Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of home inspections to identify unacted-on regulatory lift examination faults
Wider context from the report
“4. In inspections of the home, the CQC did not pick up that there were faults identified in the regulatory examination that had not been acted upon; ”
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 Serendipity Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to read, act on, and escalate regulatory lift examination findings
Wider context from the report
“2. The evidence given to the inquest was that there was a gap in the system which meant that regulatory lift examinations could take place but not be read or acted upon, with no escalation process; ”
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 Serendipity Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to require lift servicing and repair engineers to obtain regulatory examination reports
Wider context from the report
“6. That the lift company Lancs and Cumbria engineers carrying out serving/repairs were not expected to ask to see the regulatory examination reports; ”
Open source report

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 raised8

Lack of statutory minimum requirements for lift servicing

Lack of a care home system for reviewing and passing lift examination details to the servicing company

Lack of formal minimum qualification standards for lift engineers

Lack of clarity about informing engineers of and following up regulatory lift examination requirements

Electronic lift servicing appointment systems lacking checklists

Failure of home inspections to identify unacted-on regulatory lift examination faults

Failure to read, act on, and escalate regulatory lift examination findings

Failure to require lift servicing and repair engineers to obtain regulatory examination reports