2 Jun 2026 Francis Leech · Prevention of Future Deaths report Worcestershire
View report summary
Concerns raised 4 Lack of management system for checking and ensuring care and behavioural support plans are updated View source Lack of staff understanding of the importance of updating care and behavioural support plans View source Failure of internal investigations to identify care-plan deficiencies and prevent their repetition View source Failure to update care and behavioural support plans to reflect aggression, risk and risk-reduction measures View source See 1 more concern
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
×
AI-generated summary
Francis Leech · 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
Francis Leech, who had advanced dementia and other significant medical conditions, died on 26 August 2024 after a decline following severe facial injuries inflicted by another care home resident. The principal concerns were that the resident’s aggressive behaviour and associated risks were not properly reflected in updated care and behavioural support plans, and that management and the subsequent internal investigation failed to identify or address these deficiencies.
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 Managing Director, Adept Care Homes; that does not assign responsibility.
PFD Monitor interpretation Lack of management system for checking and ensuring care and behavioural support plans are updated
Wider context from the report “The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated ; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated.
” 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 Managing Director, Adept Care Homes; that does not assign responsibility.
PFD Monitor interpretation Lack of staff understanding of the importance of updating care and behavioural support plans
Wider context from the report “The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan ; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated.
” 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 Managing Director, Adept Care Homes; that does not assign responsibility.
PFD Monitor interpretation Failure of internal investigations to identify care-plan deficiencies and prevent their repetition
Wider context from the report “The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated .
” 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 Managing Director, Adept Care Homes; that does not assign responsibility.
PFD Monitor interpretation Failure to update care and behavioural support plans to reflect aggression, risk and risk-reduction measures
Wider context from the report “The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk . The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated.
” Open source report
Pin
Request correction
Information checked against published PFD reports and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations