Recipient

The Oaks & Woodcroft

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First report 27 Feb 2023•Latest report 27 Feb 2023

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Residential care 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 Oaks & Woodcroft linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Norfolk

    AI-generated summary

    Peter Gary SEABY · 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

    Peter Gary Seaby was a resident of The Oaks and Woodcroft Care Home who died in hospital on 22 May 2018 after choking-related symptoms and subsequent aspiration pneumonia. His lunchtime food was not prepared in accordance with his SALT Care Plan, and he did not receive the required one-to-one supervision; the inquest found these possibly contributed to his death. The report also identified concerns about informal care arrangements, staffing levels, and the absence of an internal review after his death.

    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 Oaks & Woodcroft; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to conduct an internal review following an unexpected resident death

    Wider context from the report

    “3. Mr Seaby died in 2018 and this is the second inquest into Mr Seaby’s death. There has still been no internal review carried out following Mr Seaby’s death which was unexpected. No Manager was present throughout the inquest and when some elements of evidence were put in dealing with Regulation 28 matters there was some surprise at some of the points raised in evidence heard during the course of the inquest. ”
    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 Oaks & Woodcroft; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient staffing levels for resident care and supervision

    Wider context from the report

    “2. It was not clear from the evidence that the staffing levels at Oaks and Woodcroft Care Home are sufficient to provide care for residents, including those requiring one to one supervision and supervision out of the Home and to cover individual activities ”
    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 Oaks & Woodcroft; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to formalise allocation of resident supervision and meal preparation duties

    Wider context from the report

    “1. Evidence was heard at the inquest of the “informal approach” taken with regard to arrangements as to who would provide supervision of residents, including on a one to one basis and who would cook and prepare their meals, including those residents who were subject to a specific SALT dietary plan. Evidence was also heard of steps which have been put in place since Mr Seaby’s death to provide written staff rotas for such matters, prepared by Team Leaders and Deputy Managers. However, despite these steps being taken, evidence was also heard at the inquest from staff, who continue to provide care at Oaks and Woodcroft Care Home, referring to providing care on an “informal basis” and that this “works”. ”
    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