Recipient

Tanglewood Cloverleaf

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First report 14 Sep 2022•Latest report 14 Sep 2022

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Nursing 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 Tanglewood Cloverleaf linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Lincolnshire

    AI-generated summary

    Lilian SHEARING · 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

    Lilian SHEARING died in Lincoln County Hospital on 29 September 2019 after admission for unrelated medical treatment. Before her hospital admission, poor fluid intake was recorded at her care home, but no risk assessment was undertaken and omissions were made from the fluid intake chart; her intake was later estimated to have been approximately 25% of the expected level due to dehydration.

    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 Tanglewood Cloverleaf; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake risk assessments for poor fluid and nutritional intake

    Wider context from the report

    “Upon admission on 11th July 2019 to your care home it was recorded at handover the deceased had a poor fluid intake. Despite this no risk assessment was undertaken. Omissions were also made from the fluid intake chart. It was conceded at Inquest today by your regional manager that the deceased's fluid intake was approximately 25% of where it should have been before her admission to hospital on 23rd August 2019 due to dehydration. Policies/assessments were clearly not in place to cover this eventuality. What are your current policies re risk assessments for fluid and nutritional intake? ”
    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 Tanglewood Cloverleaf; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to record fluid intake accurately

    Wider context from the report

    “Upon admission on 11th July 2019 to your care home it was recorded at handover the deceased had a poor fluid intake. Despite this no risk assessment was undertaken. Omissions were also made from the fluid intake chart. It was conceded at Inquest today by your regional manager that the deceased's fluid intake was approximately 25% of where it should have been before her admission to hospital on 23rd August 2019 due to dehydration. Policies/assessments were clearly not in place to cover this eventuality. What are your current policies re risk assessments for fluid and nutritional intake? ”
    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 Tanglewood Cloverleaf; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of policies governing risks from poor fluid and nutritional intake

    Wider context from the report

    “Upon admission on 11th July 2019 to your care home it was recorded at handover the deceased had a poor fluid intake. Despite this no risk assessment was undertaken. Omissions were also made from the fluid intake chart. It was conceded at Inquest today by your regional manager that the deceased's fluid intake was approximately 25% of where it should have been before her admission to hospital on 23rd August 2019 due to dehydration. Policies/assessments were clearly not in place to cover this eventuality. What are your current policies re risk assessments for fluid and nutritional intake? ”
    Open source report
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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