Recipient

The Vicarage

First report 1 Dec 2020•Latest report 1 Dec 2020

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
Published responses: 0%
Concerns addressed: 0
Stated actions: 0

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

1 Dec2020
Manchester South
Concerns raised6
1. Failure to maintain staff clarity about PPE requirements
2. Limited documentation of care home staff observations
3. Failure to share and implement changes to PPE guidance
1. Lack of risk assessment for admission of new residents
2. Failure to undertake observations of sufficient quality
3. Insufficient ambulance availability for timely transport to an acute setting
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

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

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

Reports, concerns and published responses

Reports over time

Concerns raised6

Failure to maintain staff clarity about PPE requirements

Limited documentation of care home staff observations

Failure to share and implement changes to PPE guidance

Lack of risk assessment for admission of new residents

Failure to undertake observations of sufficient quality

Insufficient ambulance availability for timely transport to an acute setting