Recipient

Tadworth Grove Care Home

Pin Request correction

First report 7 Mar 2022•Latest report 7 Mar 2022

Recipient record

Reports, concerns and published responses

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

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

Reports over time

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 Tadworth Grove Care Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Surrey

    AI-generated summary

    Michael John Humphries · 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

    Michael John Humphries, who was quadriplegic and diabetic, was admitted to hospital on 20 March 2019 with severe sepsis and died on 30 March 2019 after being placed into palliative care. Concerns included the lack of information about the proper use of a Tbar cushion, inadequate wound-care knowledge and documentation, limited access to suitable dressings, and an ineffective initial referral process to tissue viability nurses.

    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 Tadworth Grove Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Inadequate wound care knowledge

    Wider context from the report

    “1. Tbar cushion arrived with Michael without any information on its proper use. 2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound. 3. Wound care knowledge was not adequate. 4. Provision of correct dressings not available to non-TVN professionals. 5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care. 6. Information may be useful to National Wound Care Strategy. ”
    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 Tadworth Grove Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of information on proper use of Tbar cushions

    Wider context from the report

    “1. Tbar cushion arrived with Michael without any information on its proper use. 2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound. 3. Wound care knowledge was not adequate. 4. Provision of correct dressings not available to non-TVN professionals. 5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care. 6. Information may be useful to National Wound Care Strategy. ”
    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 Tadworth Grove Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain accurate wound tracking documentation

    Wider context from the report

    “1. Tbar cushion arrived with Michael without any information on its proper use. 2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound. 3. Wound care knowledge was not adequate. 4. Provision of correct dressings not available to non-TVN professionals. 5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care. 6. Information may be useful to National Wound Care Strategy. ”
    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 Tadworth Grove Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the TVN referral and initial telephone consultation process to identify wound care issues

    Wider context from the report

    “1. Tbar cushion arrived with Michael without any information on its proper use. 2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound. 3. Wound care knowledge was not adequate. 4. Provision of correct dressings not available to non-TVN professionals. 5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care. 6. Information may be useful to National Wound Care Strategy. ”
    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 Tadworth Grove Care Home; that does not assign responsibility.

    PFD Monitor interpretation

    Unavailability of correct dressings to non-TVN professionals

    Wider context from the report

    “1. Tbar cushion arrived with Michael without any information on its proper use. 2. I have seen the documentation from the care home where the wound tracking documents are poorly filled in and incorrect information has been recorded. This has made it more difficult to chart the progress of this wound. 3. Wound care knowledge was not adequate. 4. Provision of correct dressings not available to non-TVN professionals. 5. Referral system with TVNs was not useful in Michael’s case. Initial consultation by telephone was unable to identify issues that would have assisted wound care. 6. Information may be useful to National Wound Care Strategy. ”
    Open source report
Back to top

Published response patterns

Compared with other recipients in reports included in PFD Monitor

Describes published response evidence, not performance.

Published responses found

0%
0%All other recipients 58%
0%100%

How actions were described at the time

This respondent
All other recipients
47%25%27%<1%<1%
  • Completed
  • In progress
  • Planned
  • Unclear
  • Partially completed

Statuses reflect what recipients said at the time. PFD Monitor does not verify whether actions happened.

Types of action described in responses

Percentages use all actions described by each group. An action may have more than one type, so percentages do not total 100%.

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