Recipient

The Heathers Nursing Home

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First report 9 May 2014•Latest report 9 May 2014

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 The Heathers Nursing Home linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Norfolk

    AI-generated summary

    MARGARET CONNOR · 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

    Margaret Connor, a resident of Heathers Nursing Home, probably suffered a right leg fracture when a wheelchair footplate was misplaced on 3 July 2013. The fracture was not detected until hospital admission and imaging, and she died on 2 August 2013; the post-mortem report stated that debility caused by the fracture was likely to have contributed to her death. Concerns included inadequate checks and maintenance of wheelchair footplates, and doctors being told there had been no trauma despite concerns about an injury.

    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 Heathers Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to ensure wheelchairs have secure, correctly matched footplates

    Wider context from the report

    “(2) Wheelchairs are left in the alcove ready for use without footplates, loose footplates and mismatched footplates. ”
    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 Heathers Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient pre-use checking of wheelchairs

    Wider context from the report

    “(1) Insufficient procedures are in place to check wheelchairs before use. Carers collect a wheelchair from an alcove and are required to check over before it is used. It would appear this is not always being done. ”
    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 Heathers Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to communicate wheelchair-related injury concerns accurately to attending doctors

    Wider context from the report

    “(3) The attending Doctors were being told there had been “no trauma” to Mrs Connor's leg, despite concerns being raised by her family that her foot/leg had been injured on the wheelchair and despite the faulty plate having been seen by staff. ”
    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 Heathers Nursing Home; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient independent post-use checks of wheelchairs

    Wider context from the report

    “(3) There are insufficient/no independent checks being carried out on wheelchairs on their return to the alcove. They are only referred to “the maintenance man” if there is something noted to be wrong with them. ”
    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