Recipient

Springbank Care Home Limited

First report 17 Dec 2013•Latest report 17 Dec 2013

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 100%
Concerns addressed: 2
Stated actions: 7

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.

100%published responses found

7stated actions described

Topic comparisons are not available in the current evidence snapshot.

Concerns and recipient responses

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

17 Dec2013
Cardiff & the Vale of Glamorgan
Concerns raised3
1. Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness
2. Failure to provide early medical attention for gradual onset stroke
3. Failure to seek medical opinion for prolonged unconsciousness
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 6
1. Action
  Provide all staff with first-aid and life-support training focused on the immediate care of unconscious residents.
  Stated planned
2. Action
  Assess nurses’ competency in recognising consciousness levels, providing and documenting life support, conducting neurological observations, and following relevant guidance.
  Stated planned
3. Action
  Instruct staff to summon emergency services promptly for unconscious residents, follow valid DNNAR instructions, and use a protocol available to all staff.
  Stated completed
1. Action
  Inform nurse agencies and provide their head offices with the unconscious-person management protocol.
  Stated planned
2. Action
  Provide the unconscious-person management protocol to occasional staff through agency induction materials.
  Stated completed
3. Action
  Update residents’ risk assessments and care plans with specific information about causes of unconsciousness, including detailed epilepsy seizure types and recovery periods.
  Stated planned
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
Page 3 · response
Published 17 December 2013
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
Page 3 · response
Published 17 December 2013
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
Page 4 · response
Published 17 December 2013
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
Page 4 · response
Published 17 December 2013
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
Page 4 · response
Published 17 December 2013
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
Page 4 · response
Published 17 December 2013
Open published response

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 raised3

Risk of unnecessary death or injury to residents treated without appropriate assessment of unconsciousness

Failure to provide early medical attention for gradual onset stroke

Failure to seek medical opinion for prolonged unconsciousness

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

Actions described in response 6