10 Jan 2018 John Keith Edwards · Prevention of Future Deaths report Staffordshire South
View report summary
Concerns raised 13 Inadequate falls management policy View source Failure to ensure availability and administration of prescribed medication View source Failure of placement and disability nursing visits to identify deterioration View source Failure to seek medical assistance following seizures View source Use of a non-patient-specific mattress View source Failure to recognise residents’ deteriorating condition View source Failure to deal with significant bruising View source Failure to seek and communicate appropriate medical follow-up for deteriorating residents View source Use of a seizure policy not specific to the resident View source Use of non-patient-specific dressings for pressure sores View source Lack of a pressure sore prevention and care policy View source Failure to provide a care placement able to cope with complex care needs View source Retrospective completion of care records View source See 10 more concerns
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John Keith Edwards · 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
John Keith Edwards, aged 64, was admitted to a care home for respite and subsequently suffered falls, seizures, reduced mobility, pressure sores and a rapid decline before dying in a nursing home on 19 December 2016. Concerns included inadequate care-home policies and care, failures to seek medical assistance and recognise deterioration, poor record-keeping, and inappropriate placement for his complex needs.
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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Inadequate falls management policy
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure availability and administration of prescribed medication
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Failure of placement and disability nursing visits to identify deterioration
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Failure to seek medical assistance following seizures
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Use of a non-patient-specific mattress
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Failure to recognise residents’ deteriorating condition
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Failure to deal with significant bruising
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Failure to seek and communicate appropriate medical follow-up for deteriorating residents
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done .
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Use of a seizure policy not specific to the resident
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Use of non-patient-specific dressings for pressure sores
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Lack of a pressure sore prevention and care policy
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Failure to provide a care placement able to cope with complex care needs
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs . Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” 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 Southwinds; that does not assign responsibility.
PFD Monitor interpretation Retrospective completion of care records
Wider context from the report “(1) Southwinds Care home did not appear to be able to cope with Mr Edwards complex care needs. Consequently the original placement appeared to be inappropriate
(2) The Care Home had an inadequate policy to deal with falls and no policy for pressure sore prevention and care
(3) Care Home staff applied a seizure policy which was not specific to the resident.
(4) Care Home staff failed to seek medical assistance following seizures.
(5) Care Home staff failed to deal with significant bruising which developed 8 days after admission to the Care Home.
(6) Care records were retrospectively filled in.
(7) Staff and management failed to recognise and seek help for the residents deteriorating condition other than by way of an out of hours attendance when the GP was given minimal information and the urgent follow up request was not done.
(8) Staff were unaware that medication brought in by the family was available to Mr Edwards, therefore it was not given. None was sought from the GP.
(9) Non patient specific dressings were used on pressure sores.
(10) A non-patient specific mattress was used on his bed.
(11) Visits by the placement officer and disability nurse failed to identify Mr Edward’s deteriorating condition.
” Open source report
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations