Recipient

Stockton Care Limited

First report 14 Mar 2024•Latest report 14 Mar 2024

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: 1
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 Stockton Care Limited linked to the concerns in each report. Select any concern, action or position to view the source wording.

14 Mar2024
Teesside and Hartlepool
Concerns raised1
1. Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
Actions described in response 5
1. Action
  Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.
  Stated completed
2. Action
  Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.
  Stated in progress
3. Action
  Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.
  Stated planned
1. Action
  Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.
  Stated planned
2. Action
  Communicate the coroner’s concerns and effective communication requirements to all staff.
  Stated completed
AI-generated summary

Victor Valentine Costello · 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

Victor Valentine Costello, a resident at Primrose Court Nursing Home, was taken to hospital on 17 February 2020 and died there six days later from naturally occurring disease. Concerns were raised that information about his drinking water despite being nil by mouth and PEG fed was not effectively communicated to staff.

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 Stockton Care Limited; that does not assign responsibility.
PFD Monitor interpretation
Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
Wider context from the report
“Mr Costello was nil by mouth and PEG fed. His family raised concerns that Mr Costello had told them he had been drinking water from the taps in his bathroom. Evidence was given at the inquest by the Nursing Home Manager that such concerns were communicated to all staff. However, further evidence given at the inquest showed that such communication was not effective (the nurse in charge and the two care assistants who were on duty on the morning Mr Costello was taken to hospital, all denied being aware of such concerns). ”
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
Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.

Verbatim wording from the response
“We have made sure that effective and robust handovers take place between day and night staff to include explaining risks associated with | Home Manger- ████████ All nursing and senior staff, | Ongoing.”

Source location
Response from Stockton Care LTD
Page 1 · response
Published 19 March 2024
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
Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.

Verbatim wording from the response
“The management will monitor handovers as part of our regular audits. We are also making sure that for all residents who are on modified diet and fluids, their risk assessments and care plans are detailed and will be shared with next of kin to make sure all the information is correct. | ████████- Operations Director, will keep their record of our checks and any shortfalls will be addressed. | On going”

Source location
Response from Stockton Care LTD
Page 2 · response
Published 19 March 2024
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
Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.

Verbatim wording from the response
“We are implementing an upgraded cloud based electronic documentation system where staff can easily look at each residents’ risks, alerts, and special instructions. | Chief Executive- ████████ Operation Director- ████████ Home Manger- ████████ All nursing and senior staff | The full implementation of the new electronic documentation system will be on 1st June 2024.”

Source location
Response from Stockton Care LTD
Page 1 · response
Published 19 March 2024
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
Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.

Verbatim wording from the response
“Actions | Responsible people | Time Scale We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. | Chief Executive- ████████ Operation Director- ████████ Home Manger- ████████ All nursing and senior staff | We had an all staff meeting on 22nd March 2024. We will schedule further meetings for those staff who did not attend.”

Source location
Response from Stockton Care LTD
Page 1 · response
Published 19 March 2024
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
Communicate the coroner’s concerns and effective communication requirements to all staff.

Verbatim wording from the response
“Actions | Responsible people | Time Scale We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. | Chief Executive- ████████ Operation Director- ████████ Home Manger- ████████ All nursing and senior staff | We had an all staff meeting on 22nd March 2024. We will schedule further meetings for those staff who did not attend.”

Source location
Response from Stockton Care LTD
Page 1 · response
Published 19 March 2024
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 raised1

Failure to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff

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.5

Actions described in response 5