Tanglewood Cloverleaf

Private and voluntary organisations · Nursing home

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First report 14 Sep 2022•Latest report 14 Sep 2022

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 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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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