Concerns raised 10 Failure to maintain adequate records View source Failure of fragmented record systems to support clear follow-up View source Failure to ensure accurate recording of treatment site View source Delays in confirming podiatry referral messages View source Failure to investigate and review procedures, training and protocols View source Failure to provide timely and accurate D.O.L.S. status information View source Lack of staff training for dealing with this type of matter View source Failure of staff to remain and assist with transfer to a suitable procedure location View source Lack of nurse training on contacting the Clinical manager View source Failure to provide a clean and appropriate setting for podiatry procedures View source See 7 more concerns
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AI-generated summary
William Gordon Tolen · 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
William Gordon Tolen was living at Shawe Lodge when he developed problems with his legs and left great toenail; a podiatrist removed the toenail, after which he developed cellulitis. The investigation concluded that the death was from natural causes, with septicaemia and cellulitis recorded as the medical cause of death. Concerns included inadequate record-keeping, delays in arranging podiatry care, insufficient staff training, and the inappropriate conditions in which the procedure was carried out.
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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain adequate records
Wider context from the report “1. The quality of note recording and keeping at the home fell a very long way short of what might be considered satisfactory . The effect of this was that the member of staff giving evidence was unable to confirm many facts because they were simply not recorded either properly or at all .(Shawe Lodge)
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure of fragmented record systems to support clear follow-up
Wider context from the report “6. The details kept in the daily “Diary” at the home were grossly inadequate , an example being “chase up podiatry (sic) for William” on the 19th February. He was known as Gordon. No-one appears to have pursued this or noted that the podiatrist did not attend the 24th February , thereby the whole system of notes being kept in a diary, in a separate individual note file, in MDT visits book and in a GP visits book appears inevitably to lead to confusion .(Shawe Lodge)
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure accurate recording of treatment site
Wider context from the report “5. The notes at Shawe Lodge indicated that the nail had been removed from the “right” great toe when in fact it was the left . This was apparently due to a misinterpretation of an abbreviation in those notes . (Shawe Lodge)
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Delays in confirming podiatry referral messages
Wider context from the report “2. The need for the attendance of a podiatrist was, or should have been apparent to the staff at the home, and yet they allowed 5 days to pass without ensuring that their messages had been received , hence there was a delay before Mr Tolen was seen and treated .(Shawe Lodge)
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to investigate and review procedures, training and protocols
Wider context from the report “4. Following this death, there has been no form of investigation by Shawe Lodge to review procedure, training or protocols within the home . (Shawe Lodge)
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide timely and accurate D.O.L.S. status information
Wider context from the report “9. Extremely late in the inquest hearing, I was informed by the attending staff from Shawe Lodge, that Mr Tolen was subject to a D.O.L.S order when he was resident there. This information, which subsequently proved to be erroneous, could have been of vital importance .(Shawe Lodge)
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Lack of staff training for dealing with this type of matter
Wider context from the report “3. The witness from Shawe Lodge confirmed in evidence that the staff did not have any training in relation to dealing with this type of matter and that the nurses were not trained as to the fact that they could and should contact the Clinical manager in such cases.
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure of staff to remain and assist with transfer to a suitable procedure location
Wider context from the report “7. The Podiatrist attended and was left with the patient in the sitting room. The Shawe Lodge staff did not remain and did not offer to assist with his removal to a more suitable location for the procedure to take place . (Shawe Lodge)
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Lack of nurse training on contacting the Clinical manager
Wider context from the report “3. The witness from Shawe Lodge confirmed in evidence that the staff did not have any training in relation to dealing with this type of matter and that the nurses were not trained as to the fact that they could and should contact the Clinical manager in such cases .
” 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 Shawe Lodge Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a clean and appropriate setting for podiatry procedures
Wider context from the report “8. The podiatrist carried out a procedure in the sitting room . She had to remove food debris and other detritus from around Mr Tolen’s feet before she could put down plastic sheets . This practice rendered both Mr Tolen and other residents at risk of infection and it was wholly inappropriate to carry out such a procedure in this way ████████
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations