St Mary's Nursing Home

Private and voluntary organisations · Nursing-home operator

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First report 10 Jan 2014•Latest report 10 Jan 2014

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

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.

  1. Coventry

    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
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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