Recipient

Son and daughter-in-law of the deceased

First report 16 Jun 2014•Latest report 16 Jun 2014

Recipient record

Reports, concerns and published responses

This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports
1

Naming this recipient

Published responses
0%

Found for named reports

Concerns addressed
0

Across all linked responses

Stated actions
0

Described in responses

Reports over time

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.

0%published responses found
0stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

Statements from Son and daughter-in-law of the deceased linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Cornwall

    AI-generated summary

    Mrs Care · 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

    Mrs Care, an 86-year-old woman with poor mobility, was transferred to Helston Hospital for rehabilitation after treatment at Treliske and died there on 12 October 2013 after rapidly deteriorating. Extensive bruising and a soft tissue haematoma were found, with the haematoma recorded as contributory to her death; the inquest found it was more likely than not that trauma caused the bruising during her stay at the Royal Cornwall Hospital, but its precise cause was not established. The report also raises concerns that an Allow Natural Death Order was not communicated to the family and that their calls about the bruising were not returned.

    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 Son and daughter-in-law of the deceased; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to establish how patient trauma was sustained during hoist transfers

    Wider context from the report

    “At inquest I found as a matter of fact that it was more likely than not that trauma caused the extensive bruising seen on Mrs Care’s hip and abdomen at post-mortem. I further found that it was more likely than not that this trauma was sustained during Mrs Care’s stay in the Royal Cornwall Hospital. Evidence was read out at inquest that nothing untoward happened during the ambulance transfer. The bruising itself was discovered at the time of Mrs Care’s admission into Helston Community Hospital. I was not able to offer the family an explanation at inquest as to how this trauma had been sustained. That is plainly undesirable and it is for this reason that I write to bring this matter to your attention. You will understand that the pathologist found the extensive soft tissue haematoma was contributory to Mrs Care’s death, something the family described as “a sad state of affairs”. During the course of the inquest it was drawn to my attention that owing to the fact Mrs Care had become immobile she was being moved with a hoist. It was speculated that this may be the cause of the bruising that was seen. I had no evidence, however, from anyone who had been involved in moving Mrs Care by this means. ”
    Open source report
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Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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