14 Nov 2025 Ronald PERRY · Prevention of Future Deaths report Manchester South
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Concerns raised 4 Failure to adhere to the falls policy for unwitnessed falls in residents on anticoagulation View source Limited staff understanding of the falls policy for unwitnessed falls in residents on anticoagulation View source Failure to adequately document care, risk and steps taken View source Failure to complete and update falls risk assessments after falls View source See 1 more concern
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AI-generated summary
Ronald PERRY · 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
Ronald Perry became increasingly frail after discharge to The Lakes Care Home and experienced several falls, including a fall on 25 April 2025 that resulted in a brain bleed and fractures. He deteriorated after surgery and died at Salford Royal Hospital on 30 May 2025. Concerns included poor care and risk documentation, incomplete falls risk assessments, and inconsistent adherence to the policy on seeking medical advice for unwitnessed falls involving residents on anticoagulants.
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× 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to adhere to the falls policy for unwitnessed falls in residents on anticoagulation
Wider context from the report “3. The falls policy regarding the need to seek medical advice where a resident on anticoagulation had a fall that had been unwitnessed did not seem to be widely understood by staff or adhered to on all occasions .
” 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Limited staff understanding of the falls policy for unwitnessed falls in residents on anticoagulation
Wider context from the report “3. The falls policy regarding the need to seek medical advice where a resident on anticoagulation had a fall that had been unwitnessed did not seem to be widely understood by staff or adhered to on all occasions.
” 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to adequately document care, risk and steps taken
Wider context from the report “1. During the course of the inquest it was difficult to be clear at times as to what care had been delivered or what steps had been taken because the documentation relating to care and risk was poor .
” 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to complete and update falls risk assessments after falls
Wider context from the report “2. The falls risk assessment documentation was incomplete and did not appear to have been updated after falls had occurred .
” Open source report
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Allocate monthly care-plan and risk-assessment reviews to Senior Carers and Leaders, with interim updates communicated to staff.
Verbatim wording from the response “b) Care Plan – Reviews These are now allocated to certain key individuals (All Seniors Carers and Leaders) to ensure all are checked at least monthly and any updates added. If changes occur in between reviews then the Care Plan and Riska assessments are updated accordingly and communicated with the teams.” Source location Response from The Lakes Care Centre
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Retrain all Senior Carers on falls management, including seeking support and applying the falls protocol for unwitnessed falls involving anticoagulated residents.
Verbatim wording from the response “The Lakes Care centre agrees that some people charged with supporting our residents, did not fully understand the policy and protocols that re in place when people experience falls at The Lakes Care Centre.” Source location Response from The Lakes Care Centre
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Assess workforce suitability, replace unsuitable influential staff and appoint new key personnel to improve practice.
Verbatim wording from the response “c) Whole Team Skill Review – The Leadership Team at The Lakes assessed its employees and whether or not they were fit for the role they were employed in and if they were in the right role within the Lakes. This resulted in a number of key people (who led teams and influenced practice) leaving our organisation. We then appointed new key people to help us move forward with our agenda of positive outcomes and impact for all people who use and visit our service. To date this is going well and we are now seeing big improvements in routine and regular practice improving, form better shift handovers, record keeping, referring on to specialist services and all resulting in a reduction in complaints, concerns and leading to more compliments about how we respond to issues and deliver support to our lovely residents.” Source location Response from The Lakes Care Centre
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Improve use of the Digital Care Record system for care documentation, auditing and governance.
Verbatim wording from the response “In addition to this we have undertaken a review of our Digital Care Record system and with Tameside’s support began using it much more effectively in terms of auditing and governance. This has led to improvements in protocols such as fall management. In addition, we have improved in the following areas:” Source location Response from The Lakes Care Centre
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Adopt a comprehensive pre-admission protocol to create complete care plans and risk assessments from admission.
Verbatim wording from the response “a) Pre/New Admission Protocol – we adopted a new and thorough approach which enables our team to ensure we have all information to create a full and complete Care Plan from Day 1 and ensure all accompanying Risk Assessments are in place to support the Care Plans.” Source location Response from The Lakes Care Centre
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement falls protocols requiring every fall to be reported, digitally recorded and followed by reassessment when needs may have changed.
Verbatim wording from the response “The Lakes Care Centre now has clear guidelines and protocols to follow in all falls – whether serious or apparently innocuous. The guidance now direct people to report on every occasion (using Digital health – during operating hours, NHS 11 support or NHS 999 support).” Source location Response from The Lakes Care Centre
Open published response
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Source evidence
How this respondent action was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation Implement a Senior Falls Champion role responsible for coaching, training and assessing staff on falls and falls-risk management.
Verbatim wording from the response “Finally, after all this soul searching and reviewing we have now implemented a Falls Champion at The Lakes. The Champion is a Senior Person and will undertake in collaboration with Nottingham University, a 5-week training and awareness training programme. This will equip them with the knowledge and skills to be able to effect positive responses to all falls and falls risk management. They will be responsible to coaching, training and assessing our teams for their approach to this subject.” Source location Response from The Lakes Care Centre
Open published response
6 Sep 2024 John Francis HOWLETT · Prevention of Future Deaths report Manchester South
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Concerns raised 2 Lack of robust monitoring of care-home residents' nutritional status and fluid intake View source Failure to move patients from emergency departments onto wards in a timely manner due to capacity constraints View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
John Francis HOWLETT · 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
John Francis Howlett had severe chronic obstructive pulmonary disease, was bedbound and required oxygen in a care home, where he became increasingly frail with poor nutrition and fluid intake. He developed an infection, was admitted to hospital, and died on 31 January 2024 after continuing to decline. Concerns included his spending 22 hours in an emergency department corridor and the care home’s inadequate systems for robustly monitoring his nutritional status and fluid intake.
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× 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of robust monitoring of care-home residents' nutritional status and fluid intake
Wider context from the report “2. The evidence before the inquest indicated that the care home in question had been of concern in relation to the care offered to residents for some time. It was indicated that action plans were in place particularly in relation to safeguarding concerns given the vulnerability of residents. However despite those steps being in place and the concerns the systems were not in place at the care home to robustly monitor his nutritional status and fluid intake . He became increasingly frail with decreased physiological reserves as a consequence.
” 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to move patients from emergency departments onto wards in a timely manner due to capacity constraints
Wider context from the report “1. The inquest heard that on arrival at A and E at Tameside Hospital Mr Howlett spent 22 hours in a corridor despite suffering from an infection and the distress that this caused. The inquest was told that this was due to the demands on the department and the challenges of moving patients onto wards due to capacity issues . The inquest was told that this was not unique to that particular day or indeed to the hospital and was the picture across the country at that time .
” Open source report
2 May 2024 Frederick Martin Gerard Boyd · Prevention of Future Deaths report Manchester South
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Concerns raised 5 Lack of a clear system or expectation for the quality of checks on unwell residents View source Limited documentation of key periods View source Limited senior-manager oversight of documentation quality View source Unclear and poorly understood escalation system for unwell patients View source Limited staff understanding of the level of detail required in documentation View source See 2 more concerns
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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AI-generated summary
Frederick Martin Gerard Boyd · 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
Frederick Martin Gerard Boyd, a resident of Lakes Care Home with a long-term catheter, complained of severe abdominal pain on 10 September 2023 and was found unresponsive in bed at about 6am the following day. A postmortem found that he died from peritonitis due to a bladder perforation caused by long-term catheterisation. Concerns included the lack of clear systems for monitoring and escalating care when a resident was unwell, limited documentation, and limited managerial oversight of documentation quality.
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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Lack of a clear system or expectation for the quality of checks on unwell residents
Wider context from the report “1. The inquest heard evidence that there was no clear system or expectation regarding the quality of checks on a resident who exhibited signs of being unwell .
” 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Limited documentation of key periods
Wider context from the report “2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited.
” 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Limited senior-manager oversight of documentation quality
Wider context from the report “2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited .
” 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Unclear and poorly understood escalation system for unwell patients
Wider context from the report “3. The evidence before the inquest indicated that the system for escalation where a patient was unwell was unclear and not understood 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Limited staff understanding of the level of detail required in documentation
Wider context from the report “2. The evidence before the inquest was that the documentation in relation to the key period was limited and that there appeared to be a limited understanding by staff of the level of detail required and that oversight of the quality of documentation by senior managers was limited.
” Open source report
Concerns raised 1 Failure to undertake formal investigations of incidents View source
Responses linked to these concerns
Each statement is shown once, even when linked to more than one concern.
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Geoffrey Spencer · 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
Geoffrey Spencer, a resident at The Lakes Care Centre, was found on the floor after an unwitnessed fall and later died in hospital from respiratory arrest secondary to aspiration pneumonia. The principal concern was that The Lakes had not formally investigated the incident, reducing the potential for learning to improve the safety of other residents.
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× 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 Lakes Care Centre; that does not assign responsibility.
PFD Monitor interpretation Failure to undertake formal investigations of incidents
Wider context from the report “Notwithstanding the serious injury sustained by Mr Spencer, and the residual possibility that this was sustained in circumstances where the lounge area was unattended by a member of staff, it is a matter of concern that no formal investigation has been undertaken in relation to this incident by The Lakes.
Whilst evidence emerged in the course of the inquest of improvements to the Care Centre’s Falls Policy and more formal reporting and analysis of falls at The Lakes, it is a matter of concern that the absence of a formal investigation has reduced the potential for learning to be derived from this incident with a view to improving the safety of other residents.
” Open source report
Includes reports addressed to a minister or senior office-holder acting for this organisation.
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations