The Care Bureau

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First report 31 Mar 2026•Latest report 31 Mar 2026

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 The Care Bureau linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Northamptonshire

    AI-generated summary

    Mr John Hay · 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

    Mr John Hay, who lived alone and received domiciliary care, suffered an unwitnessed fall at home on 26 September 2024 and later died from a subdural haemorrhage on 2 October 2024. The report raised concerns about incomplete risk assessment, unclear escalation for medical input after a fall, and unclear processes for addressing missing or spent medication.

    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 The Care Bureau; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear process for escalating cases to obtain medical input

    Wider context from the report

    “2. The process/system for escalation to get medical input was unclear. In the current case, it was accepted with the benefit of hindsight that when a frail elderly person on blood thinners suffers a fall, a medical assessment should probably be done. However, after the morning visit, it was Mr Hay himself who made the decision (despite having suffered a fall and having a diagnosis of dementia) without input from his family. At the time of the evening visit, the care team contacted the son for a decision rather than simply assessing the situation and making a decision. ”
    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 The Care Bureau; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of the care team to assess situations and make care decisions

    Wider context from the report

    “2. The process/system for escalation to get medical input was unclear. In the current case, it was accepted with the benefit of hindsight that when a frail elderly person on blood thinners suffers a fall, a medical assessment should probably be done. However, after the morning visit, it was Mr Hay himself who made the decision (despite having suffered a fall and having a diagnosis of dementia) without input from his family. At the time of the evening visit, the care team contacted the son for a decision rather than simply assessing the situation and making a decision. ”
    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 The Care Bureau; that does not assign responsibility.

    PFD Monitor interpretation

    Unclear process for notifying the responsible person about missing or spent medication

    Wider context from the report

    “3. The process/system by which missing or spent medication is actioned was unclear. In the current case, Mr Hay’s son was responsible for ordering medication. However, the system by which the care team would notify him was unclear. ”
    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 The Care Bureau; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to complete and clinically review care-plan risk assessments

    Wider context from the report

    “1. The Risk Assessment in the Care Plan is neither completed nor reviewed with nursing or medical input, but includes, amongst other things, actions to be taken when a person is on blood thinners. In the present case, the only scenario covered was in relation to a person who has “heavy bleeding”. The obligation to complete the risk assessment and determine actions falls upon the care team, none of whom have any medical training, aside from basic first aid. ”
    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 The Care Bureau; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient coverage of blood-thinner-related scenarios in care-plan risk assessments

    Wider context from the report

    “1. The Risk Assessment in the Care Plan is neither completed nor reviewed with nursing or medical input, but includes, amongst other things, actions to be taken when a person is on blood thinners. In the present case, the only scenario covered was in relation to a person who has “heavy bleeding”. The obligation to complete the risk assessment and determine actions falls upon the care team, none of whom have any medical training, aside from basic first aid. ”
    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