Three Sisters Care Ltd

Private and voluntary organisations · Private limited company

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First report 11 Aug 2020•Latest report 11 Aug 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 Three Sisters Care Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

  1. Inner North London

    AI-generated summary

    Moses Victor Boardman · 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

    Moses Victor Boardman, an elderly and frail man, was mistakenly discharged to his home instead of sheltered accommodation, where he was found without heating, light or food and subsequently readmitted to hospital after a further cerebrovascular accident. While assessed as being at risk of aspiration and requiring supervised feeding, he was later found eating a whole fruit unsupervised, suffered a choking incident, and died at 04.48. The substantive concerns included discharge and transport safeguards, failure to escalate missed care visits, monitoring of patients fed at risk, and the response to a potential reversible cause of collapse when a DNACPR order was in place.

    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 Three Sisters Care Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to commence CPR when a reversible cause for collapse overrides a DNAR order

    Wider context from the report

    “6. The RLH failure to commence CPR when a potential reversible cause for collapse existed that would override the effect of the DNAR order. ”
    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 Three Sisters Care Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of a commissioned care provider to escalate inability to reach a patient for care visits

    Wider context from the report

    “4. The responsiveness of the care provider commissioned by LBTH to escalate the fact that they had been unable to reach Mr Boardman for his first 3 care visits. ”
    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 Three Sisters Care Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Absence of a clear computerised record explaining a change of address in the departure lounge

    Wider context from the report

    “1. The absence of a clear computerised record in the RLH departure lounge explaining the change of address. ”
    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 Three Sisters Care Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Lack of a clear safeguard ensuring vulnerable patients are discharged to the correct address

    Wider context from the report

    “2. The lack of a clear safeguard to ensure that a vulnerable patient is discharged to the correct address. ”
    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 Three Sisters Care Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure to properly monitor patients assessed as fed at risk

    Wider context from the report

    “5. The proper monitoring of patients on RLH ward 14F who have been assessed as being “fed at risk”. Specifically, why was a vulnerable patient left with unsuitable foods within his reach. ”
    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 Three Sisters Care Ltd; that does not assign responsibility.

    PFD Monitor interpretation

    Failure of transport staff to properly assess venue suitability

    Wider context from the report

    “3. The failure of RLH transport staff to properly assess the suitability of the venue that a patient is being taken to. ”
    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