25 Jun 2024 James Reginald Capstick · Prevention of Future Deaths report Cumbria
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Concerns raised 5 Failure to provide consistently good quality care View source Failure to maintain reliable clinical records View source Failure to perform and respond appropriately to basic checks and signs of life during resuscitation View source Unavailability of a defibrillator for attempted resuscitation in the care home View source Failure to retain and apply basic resuscitation training View source See 2 more concerns
No linked response statements No action or position from this recipient is clearly linked to the concerns in this report.
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James Reginald Capstick · 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
James Reginald Capstick died in hospital on 1 October 2022 after sustaining multiple rib fractures during more than 20 minutes of chest compressions when he was not in cardiac arrest, followed by respiratory insufficiency and pneumonia. The report raised concerns about the quality of care at Westmorland Court, the reliability of care records, the absence of a defibrillator at the time, and the failure to recognise signs of life during the resuscitation attempt.
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× 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 Westmorland Court Nursing and Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to provide consistently good quality care
Wider context from the report “(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally.
” 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 Westmorland Court Nursing and Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to maintain reliable clinical records
Wider context from the report “(1) To Westmorland Court. The General Practitioner who came to give evidence said that care had improved since Reg's death but he still had concerns about care given and had to visit regularly every week to check residents -the only one of six homes he covers that requires this level of support. He said it was a struggle to provide good quality care and felt this report would be helpful -as I stated at inquest it is not intended in any way to be punitive but to put focus on areas that may be improved. A particular concern was clear evidence that examinations entered into Reg's notes were made at times when this was impossible because he was in hospital -this puts into question the reliability of notes generally .
” 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 Westmorland Court Nursing and Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to perform and respond appropriately to basic checks and signs of life during resuscitation
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before. Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions . Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” 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 Westmorland Court Nursing and Residential Home; that does not assign responsibility.
PFD Monitor interpretation Unavailability of a defibrillator for attempted resuscitation in the care home
Wider context from the report “(2) To Care Quality Commission. You requested a note of the outcome of this case and please accept this report as such. I imagine you will be making further enquiries. There was no defibrillator in the home at the time of this incident although I am told one has now been installed. I was told that it is not a requirement for care homes to have one. If staff in these homes are expected to attempt resuscitation should provision be required?
” 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 Westmorland Court Nursing and Residential Home; that does not assign responsibility.
PFD Monitor interpretation Failure to retain and apply basic resuscitation training
Wider context from the report “(3) To Nursing and Midwifery Council. A Registered nurse was in charge of the home on the night of Reg's injury. Her statement told us that she forgot her basic training and had never had to attempt CPR before . Despite clear signs of breathing and resistance to her efforts she continued to be guided by the call handler at NWAS who had been confused by her inconsistent responses to his questions. Basic checks and signs of life were ignored. I was told at inquest that after being stepped down from nursing duty for a while she had had further training and was back in position. I was told that a referral to yourselves had been made and acknowledged but nothing further had been heard, has the referral been closed?
” 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