28 Nov 2022 Janice HOPPER · Prevention of Future Deaths report Norfolk
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Concerns raised 13 Inaccurate recording of food intake View source Inconsistent blood-sugar monitoring instructions across documents View source Failure of senior staff to regularly review or audit care plans View source Reliance on estimated fluid intake and output amounts View source Inaccuracies in care plans View source Failure to administer as-needed morphine only when required View source Failure to check blood sugar levels twice weekly View source Failure to prepare care plans with relevant family input View source Failure to implement recommended fluids and nutrition auditing and staff lessons-learned processes View source Failure to ensure care-plan information is resident-specific View source Failure to record fluid intake directly by the estimating staff View source Lack of recorded diabetes-specific dietary instructions View source Failure to complete scheduled weekly weighing View source See 10 more concerns
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Janice HOPPER · 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
Janice HOPPER was discharged from hospital to a care home on 31 December 2021, became unwell in January 2022, was admitted to hospital, and died on 12 February 2022. Concerns included inaccurate and inadequately reviewed care plans, failures to monitor blood glucose, food and fluid intake, and the administration of Morphine Sulphate as a matter of course despite instructions that it was to be given only as required. The inquest recorded the medical cause of death as Alzheimer's Dementia, Chronic Kidney Disease and Type 2 Diabetes Mellitus, with a conclusion of natural causes.
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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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Inaccurate recording of food intake
Wider context from the report “9. There were concerns about Mrs Hopper's food intake. It is not clear from the evidence that the amount stated in the records as being consumed was accurate . For instance, on several occasions she was noted to have consumed large amounts of fluid in one go and to have eaten more than one meal within a short space of time.
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Inconsistent blood-sugar monitoring instructions across documents
Wider context from the report “5. Mrs Hopper was diagnosed with Diabetes. The Care Plan provided for Mrs Hopper's blood sugar levels to be checked twice weekly. This information differed from information contained in other documents . Mrs Hopper's blood sugar levels were not checked until the day she presented as unwell and was admitted to hospital, some fourteen days after admission.
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Failure of senior staff to regularly review or audit care plans
Wider context from the report “11. Care Plans are not regularly reviewed or audited by senior members of staff .
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Reliance on estimated fluid intake and output amounts
Wider context from the report “7. Due to concerns about Mrs Hopper's intake of fluid, there was a recommended daily fluid intake. The amounts of fluid given to Mrs Hopper and the amounts she drank were estimated by staff .
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Inaccuracies in care plans
Wider context from the report “3. The Care Plan contained several inaccuracies such as referring to Mrs Hopper as a "man" and saying she enjoyed taking her meals in the communal dining room, when she was confined to her room due to Covid 19 isolation.
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Failure to administer as-needed morphine only when required
Wider context from the report “10. Mrs Hopper was discharged from hospital with medication including Morphine Sulphate. The written instructions were she was to be given a dose four times a day "as and when required". Mrs Hopper was given seventeen doses of Morphine Sulphate as a matter of course, regardless of whether this was required , before this was stopped by a General Practitioner.
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Failure to check blood sugar levels twice weekly
Wider context from the report “5. Mrs Hopper was diagnosed with Diabetes. The Care Plan provided for Mrs Hopper's blood sugar levels to be checked twice weekly. This information differed from information contained in other documents. Mrs Hopper's blood sugar levels were not checked until the day she presented as unwell and was admitted to hospital, some fourteen days after admission .
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Failure to prepare care plans with relevant family input
Wider context from the report “1. Mrs Hopper had dementia. The Care Plan was not prepared with input from Mrs Hopper's husband .
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Failure to implement recommended fluids and nutrition auditing and staff lessons-learned processes
Wider context from the report “12. An internal investigation carried out by the Care Home recommended review of Fluids and Nutrition be audited regularly and a "lessons learnt" document would be created for all staff. There is no evidence that these steps have been taken .
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Failure to ensure care-plan information is resident-specific
Wider context from the report “2. Evidence was heard that some information in the Care Plan purporting to relate to Mrs Hopper was "cut and paste" from another resident's Care Plan .
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Failure to record fluid intake directly by the estimating staff
Wider context from the report “8. The amount of fluid intake was not always recorded in the notes by the staff who had estimated the amount consumed but relayed to another member of staff who would complete the records .
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Lack of recorded diabetes-specific dietary instructions
Wider context from the report “6. The Care Plan provided for Mrs Hopper to be on a controlled diet due to her diagnosis of Diabetes. Evidence was heard this meant "low sugar" and staff were made aware of this orally. There was no record of any specific diet relating to Mrs Hopper or to a resident with a diagnosis of diabetes .
” 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 Windmill House; that does not assign responsibility.
PFD Monitor interpretation Failure to complete scheduled weekly weighing
Wider context from the report “4. The Care Plan provided for Mrs Hopper to be weighed weekly. She was not weighed weekly .
” 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