Recipient

Three Sisters Care Ltd

First report 11 Aug 2020•Latest report 11 Aug 2020

Recipient record

Reports, concerns and published responses

Private and voluntary organisations · Private limited company. 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 Three Sisters Care Ltd linked to the concerns in each report. Select any concern, action or position to view the source wording.

11 Aug2020
Inner North London
Concerns raised6
1. Failure to commence CPR when a reversible cause for collapse overrides a DNAR order
2. Failure of a commissioned care provider to escalate inability to reach a patient for care visits
3. Absence of a clear computerised record explaining a change of address in the departure lounge
1. Lack of a clear safeguard ensuring vulnerable patients are discharged to the correct address
2. Failure to properly monitor patients assessed as fed at risk
3. Failure of transport staff to properly assess venue suitability
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

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

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

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

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

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

Failure to properly monitor patients assessed as fed at risk

Failure of transport staff to properly assess venue suitability