Concerns raised 3 Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness View source Failure to provide early medical attention for gradual onset stroke View source Failure to seek medical opinion for prolonged unconsciousness View source
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. 6
Action
Provide all staff with first-aid and life-support training focused on the immediate care of unconscious residents.
View source
Action
Assess nurses’ competency in recognising consciousness levels, providing and documenting life support, conducting neurological observations, and following relevant guidance.
View source
Action
Instruct staff to summon emergency services promptly for unconscious residents, follow valid DNNAR instructions, and use a protocol available to all staff.
View source
Action
Inform nurse agencies and provide their head offices with the unconscious-person management protocol.
View source
Action
Provide the unconscious-person management protocol to occasional staff through agency induction materials.
View source
Action
Update residents’ risk assessments and care plans with specific information about causes of unconsciousness, including detailed epilepsy seizure types and recovery periods.
View source See 3 more actions
×
AI-generated summary
Sandra Wordingham · 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
Sandra Wordingham, a resident of Springbank nursing home, was found unconscious after a suspected epileptic fit on 22 July 2013 and remained unconscious overnight before being taken to hospital. She died in hospital on 26 July 2013; the medical cause of death was recorded as intracerebral haemorrhage. The principal concern was that no medical opinion was sought despite her remaining unconscious for longer than expected after an epileptic fit, creating a risk to similarly treated residents.
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 Springbank Care Home Limited; that does not assign responsibility.
PFD Monitor interpretation Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness
Wider context from the report “(3) Residents in an unconscious state who are treated in future in the same way as Sandra Wordingham may be at risk of unnecessary death or injury .
” 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 Springbank Care Home Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to provide early medical attention for gradual onset stroke
Wider context from the report “(2) While Sandra Wordingham suffered a profound insult which could not have been altered, had she suffered a gradual onset stroke then intervention could have been offered . In that event early medical attention would have saved her .
” 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 Springbank Care Home Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to seek medical opinion for prolonged unconsciousness
Wider context from the report “(1) Sandra Wordingham, was put to bed in the nursing home in an unconscious state after a suspected epileptic fit. In fact she had suffered a sudden primary intracerebral haemorrhage. No medical opinion was sought even though Sandra Wordingham remained unconscious throughout the night for a longer period than would be expected after an epileptic fit .
” 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 Provide all staff with first-aid and life-support training focused on the immediate care of unconscious residents.
Verbatim wording from the response “Improved First Aid & Life Support Training
All staff to attend training with specific training element for the immediate care of the unconscious person
Persons Responsible: ████████ Operations Manager Springbank & ████████ Manager
Date By: Planned for March 2014.” Source location 2013-0373-Response-by-Springbank-Nursing-Home
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 Assess nurses’ competency in recognising consciousness levels, providing and documenting life support, conducting neurological observations, and following relevant guidance.
Verbatim wording from the response “Ensuring Nursing Staff Competency
Following training and instruction nurses will have an assessment of their competency to:” Source location 2013-0373-Response-by-Springbank-Nursing-Home
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 Instruct staff to summon emergency services promptly for unconscious residents, follow valid DNNAR instructions, and use a protocol available to all staff.
Verbatim wording from the response “Summoning Emergency Assistance” Source location 2013-0373-Response-by-Springbank-Nursing-Home
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 Inform nurse agencies and provide their head offices with the unconscious-person management protocol.
Verbatim wording from the response “Providing & Sharing Information about the management of unconscious people with Bank and Agency Nurses working occasional shifts” Source location 2013-0373-Response-by-Springbank-Nursing-Home
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 Provide the unconscious-person management protocol to occasional staff through agency induction materials.
Verbatim wording from the response “Providing & Sharing Information about the management of unconscious people with Bank and Agency Nurses working occasional shifts” Source location 2013-0373-Response-by-Springbank-Nursing-Home
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 Update residents’ risk assessments and care plans with specific information about causes of unconsciousness, including detailed epilepsy seizure types and recovery periods.
Verbatim wording from the response “Knowledge of probable reasons and causes for residents who may become unconscious due to epilepsy (and other illnesses)” Source location 2013-0373-Response-by-Springbank-Nursing-Home
Open published response
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations