The Vicarage

Private and voluntary organisations · Residential care home

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First report 1 Dec 2020•Latest report 1 Dec 2020

Reports, concerns and published responses

Reports over time

Reports naming this recipient by issue year.

* 2026 is projected from reports observed to 7 Sep 2026.

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

Concerns and recipient responses

Statements from The Vicarage linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Manchester South

    AI-generated summary

    Anthony Slack · 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

    Anthony Slack, who had underlying health issues including asbestos-related pulmonary fibrosis, suffered an unwitnessed fall at a care home and waited over four hours for an ambulance. He later deteriorated, was transferred to hospital, and died on 13 April 2020. Concerns included limited care-home documentation and observations, unclear Covid-19 admission risk assessment and PPE arrangements, and ambulance delays linked to pandemic-related capacity pressures.

    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 Vicarage; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to maintain staff clarity about PPE requirements

    Wider context from the report

    “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented. ”
    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 Vicarage; that does not assign responsibility.

    PFD Monitor interpretation

    Limited documentation of care home staff observations

    Wider context from the report

    “1. The documentation available at the inquest from the home was limited in detail. As a result, it was difficult to understand what observations had been undertaken by care home staff were monitoring him. ”
    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 Vicarage; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to share and implement changes to PPE guidance

    Wider context from the report

    “4. Staff were unclear as to the PPE requirements as a result of changes to the guidance that were occurring on a regular basis and it was unclear how changes were being shared with staff and implemented. ”
    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 Vicarage; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of risk assessment for admission of new residents

    Wider context from the report

    “3. The inquest heard that after the home went into lockdown Covid 19 was found in residents within the home. At the inquest the home were unclear if staff had brought it into the home or if the admission of residents from the community who were not tested for Covid 19 before admission were the cause of the entering the home. There was no risk assessment in place relating to admission of new residents. ”
    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 Vicarage; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to undertake observations of sufficient quality

    Wider context from the report

    “2. The evidence given at the inquest was that the observations were of limited quality notwithstanding the diagnosis of Covid 19 and his vulnerability. ”
    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 Vicarage; that does not assign responsibility.

    PFD Monitor interpretation

    Insufficient ambulance availability for timely transport to an acute setting

    Wider context from the report

    “5. The inquest heard that the ambulance was delayed due to shortages of available ambulances. The inquest was told this was driven by a number of factors. This included staff absences due to the need to self-isolate awaiting testing and the increased cleaning needs in relation to ambulances required by Covid 19. The inquest was told that at some points in the day and in some acute trusts, ambulance crews were being supported by on-site cleaning crews. This meant quicker turnaround times and increased capacity. This was not consistent and not on a 24/7 basis. As a result, ambulances were struggling to reach vulnerable and unwell members of the public and transport them to an acute setting. ”
    Open source report
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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