Recipient

St Mary's Nursing Home

First report 10 Jan 2014•Latest report 10 Jan 2014

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing-home operator. This page brings together reports naming this recipient and response statements clearly connected to concerns raised in those reports.

Reports: 1
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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 St Mary's Nursing Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

10 Jan2014
Coventry
Concerns raised9
1. Failure of nursing home staff to take appropriate action when aware of low blood pressure
2. Inability of the nursing home to address future risks relating to a nurse's training
3. Lack of clarity regarding the status of the Care Quality Commission investigation
1. Failure of nursing home staff to recognise acutely unwell residents
2. Failure of nursing home managers to take action to prevent recurrence
3. Failure of nursing home managers to undertake effective incident investigations
4. Failure to provide the non-driving paramedic with satellite navigation information for hospital transfer times
5. Inaccurate reporting by nursing home managers to the Care Quality Commission
6. Lack of ongoing training in recognition and treatment of acutely unwell residents
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.

No linked response statements
No action or position from this recipient is clearly linked to the concerns in this report.
AI-generated summary

Mary WALDRON · 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

Mary Waldron became unwell at St Mary's Nursing Home on 24 August 2013 and was transferred to University Hospital, Coventry, where she died after suffering a cardiac arrest during the transfer. Concerns included failures to recognise and appropriately respond to her acute illness and low blood pressure, inadequate ongoing staff training, shortcomings in the nursing home's investigation and reporting, uncertainty about the CQC investigation, and potential confusion between ambulance drivers and paramedics about transfer times.

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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing home staff to take appropriate action when aware of low blood pressure
Wider context from the report
“(2) failure of the nursing home staff to undertake appropriate action when they were aware of the low blood pressure; ”
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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Inability of the nursing home to address future risks relating to a nurse's training
Wider context from the report
“(7) the nurse primarily involved in this incident is no longer an employee at St Mary's and is working elsewhere. St Mary's nursing home is therefore unable to take action to address potential future risks relating to the training of this nurse; ”
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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of clarity regarding the status of the Care Quality Commission investigation
Wider context from the report
“(6) lack of clarity as to the investigation that is to be undertaken by the CQC. The nursing home gave evidence that the investigation is closed, whilst the family believe it is ongoing; ”
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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing home staff to recognise acutely unwell residents
Wider context from the report
“(1) failure of the nursing home staff to recognise an acutely unwell resident; ”
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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing home managers to take action to prevent recurrence
Wider context from the report
“(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition; ”
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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure of nursing home managers to undertake effective incident investigations
Wider context from the report
“(4) failure of the nursing home managers to undertake an effective investigation into this incident and to take action to prevent repetition; ”
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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Failure to provide the non-driving paramedic with satellite navigation information for hospital transfer times
Wider context from the report
“(8) the potential for further incidents of confusion between driver and paramedic with regard to hospital transfer times, with the possibility of significant adverse consequences. Evidence given was that satellite navigation information (including time to arrival) was only available directly to the ambulance driver. Direct visualisation of a satellite navigation console by the non-driving paramedic could address this risk. ”
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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Inaccurate reporting by nursing home managers to the Care Quality Commission
Wider context from the report
“(5) inaccurate reporting by the nursing home managers to the Care Quality Commission (CQC) that internal protocols had been appropriately followed, when evidence given at the inquest was that this was not the case; ”
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 St Mary's Nursing Home; that does not assign responsibility.
PFD Monitor interpretation
Lack of ongoing training in recognition and treatment of acutely unwell residents
Wider context from the report
“(3) a lack of ongoing training with regard to the recognition and treatment of acutely unwell residents; with reliance solely on initial nursing training; ”
Open source report

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 raised9

Failure of nursing home staff to take appropriate action when aware of low blood pressure

Inability of the nursing home to address future risks relating to a nurse's training

Lack of clarity regarding the status of the Care Quality Commission investigation

Failure of nursing home staff to recognise acutely unwell residents

Failure of nursing home managers to take action to prevent recurrence

Failure of nursing home managers to undertake effective incident investigations

Failure to provide the non-driving paramedic with satellite navigation information for hospital transfer times

Inaccurate reporting by nursing home managers to the Care Quality Commission

Lack of ongoing training in recognition and treatment of acutely unwell residents