Concerns raised 7 Failure to check food records before assessing food refusal View source Inconsistent and insufficiently detailed recording of general wellbeing View source Failure to create a plan for monitoring fluid and food intake View source Delay in assessing deterioration View source Failure to record GP advice communicated at handover View source Failure to place an instruction in the room to prompt monitoring View source Lack of a single document providing a holistic view of the person View source See 4 more concerns
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AI-generated summary
John Dickinson · 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
John Dickinson was admitted to hospital after falls and treatment for a gall bladder infection, then moved to a care home. He later developed poor nutritional and fluid intake, dehydration, acute kidney impairment and a urinary tract infection, and died on 9 August 2020 while receiving palliative care. Concerns included inconsistent and insufficiently detailed record keeping, failures to document or act on advice about monitoring food and fluid intake, and delayed recognition of deterioration.
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 Sunnyside Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to check food records before assessing food refusal
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” 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 Sunnyside Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Inconsistent and insufficiently detailed recording of general wellbeing
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing .
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” 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 Sunnyside Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to create a plan for monitoring fluid and food intake
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” 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 Sunnyside Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Delay in assessing deterioration
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal .
” 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 Sunnyside Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to record GP advice communicated at handover
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned .
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” 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 Sunnyside Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Failure to place an instruction in the room to prompt monitoring
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained.
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” 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 Sunnyside Nursing Home; that does not assign responsibility.
PFD Monitor interpretation Lack of a single document providing a holistic view of the person
Wider context from the report “(1) The record keeping was inconsistent and lacked detail on general wellbeing.
(2) The volume of forms to be completed meant that there was not a single document from which a holistic view of him could be obtained .
(3) Assumptions were made regarding generally refusing food when if the food records had been checked it would have been noted that he consistently refused the fourth meal of the day until the 28th July 2020.
(4) Advice from the GP on 15th July 2020 were handed over orally at a ‘huddle’ and no record was kept as to this being mentioned.
(5) Following the GP’s visit, no action planned regarding monitoring his fluid or food intake was created nor was any instruction placed in his room to prompt monitoring.
(6) The inconsistent and sometimes non-existent record keeping meant that Mr Dickinson was not assessed as deteriorating until 48 hours before his admission to hospital rather than 5-6 days before he began refusing lunch and evening meal.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations