8 Oct 2020 May Adalaid Miller · Prevention of Future Deaths report Suffolk
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Concerns raised 4 Failure to obtain consent for disclosure of safeguarding information to other agencies View source Unclear central point of contact for investigative agencies and care homes View source Lack of a system for sharing safeguarding information with care homes View source Information-sharing arrangements failing when a person is not admitted from a registered facility View source See 1 more concern
Actions described in response An action is something this recipient says it has done, is doing, or plans to do in response to the concern raised. 1
Action
Contact receiving care homes immediately when residents consider residential care and share all available information by telephone and follow-up letter.
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AI-generated summary
May Adalaid Miller · 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
May Adalaid Miller, aged 95, was attacked by another resident while asleep at Beech House Residential Care Home on 9 February 2020 and died from natural causes precipitated by the assault. The report raised concerns about the lack of safeguarding information sharing between agencies and care facilities, including the absence of a system to share information about the other resident’s risk factors.
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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 Limes Residents Association Limited; that does not assign responsibility.
PFD Monitor interpretation Failure to obtain consent for disclosure of safeguarding information to other agencies
Wider context from the report “In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of ████████. At no time was the family of Mr ████████ asked to sign a letter giving consent to disclosure to other agencies before or after the residency. It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes.
It was established during the evidence that multiple investigative agencies may have been aware of Mr ████████’s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible.
Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller.
” 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 Limes Residents Association Limited; that does not assign responsibility.
PFD Monitor interpretation Unclear central point of contact for investigative agencies and care homes
Wider context from the report “In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of ████████. At no time was the family of Mr ████████ asked to sign a letter giving consent to disclosure to other agencies before or after the residency. It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes.
It was established during the evidence that multiple investigative agencies may have been aware of Mr ████████’s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible.
Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller.
” 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 Limes Residents Association Limited; that does not assign responsibility.
PFD Monitor interpretation Lack of a system for sharing safeguarding information with care homes
Wider context from the report “In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of ████████. At no time was the family of Mr ████████ asked to sign a letter giving consent to disclosure to other agencies before or after the residency. It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes.
It was established during the evidence that multiple investigative agencies may have been aware of Mr ████████’s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible.
Had there been in place a system for sharing safeguarding information with the Limes and Beech House , there may have been an opportunity to safeguard May Miller.
” 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 Limes Residents Association Limited; that does not assign responsibility.
PFD Monitor interpretation Information-sharing arrangements failing when a person is not admitted from a registered facility
Wider context from the report “In light of the data sharing and confidentiality requirements under GDPR, the GP was unable to disclose full information to the Limes or to Beech House about any previous conduct or assessments of ████████. At no time was the family of Mr ████████ asked to sign a letter giving consent to disclosure to other agencies before or after the residency. It was not known whether the GP could have been the central point of contact for all investigative agencies and the Care Homes.
It was established during the evidence that multiple investigative agencies may have been aware of Mr ████████’s risk factors but that due to his not having been admitted to Beech House from a registered facility, that information sharing was not possible.
Had there been in place a system for sharing safeguarding information with the Limes and Beech House, there may have been an opportunity to safeguard May Miller.
” 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 Contact receiving care homes immediately when residents consider residential care and share all available information by telephone and follow-up letter.
Verbatim wording from the response “On hearing that a resident is considering a move into residential care, contact will be made immediately with the receiving care home and all information will be shared. This would initially be by phone (warden) and would always be followed up in writing (manager)” Source location 2020-0201-Response-from-the-Limes-Residence-Association_Redacted.pdf
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Source evidence
How this respondent position was interpreted
PFD Monitor created a concise, searchable interpretation from the published response wording shown below.
PFD Monitor interpretation GP confidentiality means the suitability information received about prospective residents is very limited.
Verbatim wording from the response “Prospective residents are interviewed by the warden and the manager. A letter of suitability is always obtained from the G.P. but they seemed to be bound by confidentiality and the information is received is very limited.” Source location 2020-0201-Response-from-the-Limes-Residence-Association_Redacted.pdf
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Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations