PFD report

Ronald Colin Nelson · Prevention of Future Deaths report

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Issued 15 Jan 2026•Nottinghamshire

Report record

Published report and response evidence

This page connects the concerns raised in this report with statements found in recipients’ published responses. A link shows a clear evidence connection; it does not assign responsibility.

View original report
Concerns
2

Raised in this report

Recipients
2

Named on the report

Responses found
2

Of 2 recipients

Stated actions
14

Described in responses

Recipients and published responses

Source document

Full report text

This is the full text from the original published report.

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Concerns and recipient responses

Select any concern, action or position to view the source wording.

Concerns raised2

  1. Poor record keeping
  2. Insufficient compliance with care plans
Responses linked to these concerns

Each statement is shown once, even when linked to more than one concern.

Actions described in response An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.8

  1. Action

    Complete an unannounced assessment and associated off-site review of the care home’s safety, care planning and record-keeping arrangements.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
  2. Action

    Review wound-care plans and standardize individual wound documentation, photographs, tracking, professional instructions, and body-map oversight.

    Stated by Mulberry Healthcare LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
  3. Action

    Strengthen repositioning planning, recording and oversight through individualized Nourish schedules, care-plan documentation and regular evaluation.

    Stated by Mulberry Healthcare LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.3

  1. Position

    Record keeping and care planning were found to comply with regulations, with detailed, individualised, regularly reviewed records and plans.

    Stated by Care Quality CommissionDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Poor record keeping

Wider context from the report

“i) That there remain potential issues of poor record keeping. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this individual concern was interpreted

PFD Monitor created a concise, searchable interpretation from the report wording shown below. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Insufficient compliance with care plans

Wider context from the report

“ii) There are concerns over the level of compliance of care plans. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

Open source report

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete an unannounced assessment and associated off-site review of the care home’s safety, care planning and record-keeping arrangements.

Verbatim wording from the response

“An unannounced assessment was conducted at Mulberry Court Care Home on 17 and 18 February 2026. Further off-site assessment work continued such as reviewing documents and speaking with people. This assessment looked at key questions to determine if Mulberry Court Care Home is safe, effective, caring, responsive and well-led. Details of the assessment framework used to undertake this assessment can be found here: Assessment - Care Quality Commission.”

Source location

Response from Care Quality Commission
Page 2 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review wound-care plans and standardize individual wound documentation, photographs, tracking, professional instructions, and body-map oversight.

Verbatim wording from the response

“6. We reviewed the Wound Care Plans to ensure that they were fit for purpose, including the escalation process and that they were being used correctly and consistently by staff. Staff have been instructed to ensure;”

Source location

Response from Mulberry Court Care Home
Page 4 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Strengthen repositioning planning, recording and oversight through individualized Nourish schedules, care-plan documentation and regular evaluation.

Verbatim wording from the response

“9. We have reviewed how repositioning of residents is planned and recorded to ensure that it is person centred for the individual and addresses potential risk of harm. We have implemented further processes to make this more robust and ensure that there is appropriate oversight. This includes;”

Source location

Response from Mulberry Court Care Home
Page 6 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Strengthen communication through structured shift handovers, daily huddles and multidisciplinary meetings, with staff acknowledgment of discussed information.

Verbatim wording from the response

“7. We have reviewed communication process to ensure that staff are up to date with residents care requirements and changes in care need. We have reviewed our current processes to ensure that they are followed by staff. This includes;”

Source location

Response from Mulberry Court Care Home
Page 4 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Configure Nourish with personalized care interactions, prompts, alarms, oversight, document uploads and a professionals-and-relatives log, and train staff in its use.

Verbatim wording from the response

“10. We have a robust electronic care planning system that when staff use its full functionality it can effectively support staff to provide prompts to staff when care interventions are due, ensure that time critical care interventions are met, and alerts are triggered to senior managers if any care intervention is missed. The system also provides the NIC and RM with effective oversight of care delivery staff utilise the full functionality of Nourish and that the system is used consistently in accordance with the Company procedures. This includes:”

Source location

Response from Mulberry Court Care Home
Page 6 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review and strengthen Transfer to Hospital packs, provide staff guidance, and monitor completion weekly for six months.

Verbatim wording from the response

“4. We reviewed the Transfer to Hospital and provided further guidance to the staff about completion of the pack to ensure it contains all relevant information for the resident. The Transfer to Hospital pack ensures that the Hospital is provided with accurate information about a residents condition at the point of admission to hospital (including skin integrity and any concerns about skin breakdown). Compliance with the Transfer to Hospital pack is being reviewed on a weekly basis for a period of 6 months to ensure compliance.”

Source location

Response from Mulberry Court Care Home
Page 3 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Implement care-plan auditing and evaluation, including readmission reviews, monthly Resident of the Day reviews, and independently verified clinical supervision.

Verbatim wording from the response

“8. We have reviewed whether the current care planning systems is effective and have implemented a new auditing system to ensure that care plans are up to date, reflect residents’ needs, are understood by staff and are followed. This includes;”

Source location

Response from Mulberry Court Care Home
Page 5 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review and implement compulsory Transfer Back from Hospital packs, train nurses, and monitor compliance weekly for six months.

Verbatim wording from the response

“5. We reviewed the Transfer Back Hospital pack to ensure it remains fit for purpose and Nurses have been trained on its use. Compliance with the Transfer back Hospital pack is being reviewed on a weekly basis for a period of 6 months to ensure compliance. Use of the Transfer Back from Hospital pack is compulsory. The Pack requires;”

Source location

Response from Mulberry Court Care Home
Page 3 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Record keeping and care planning were found to comply with regulations, with detailed, individualised, regularly reviewed records and plans.

Verbatim wording from the response

“We found that record keeping and care planning at Mulberry Court Care Home is in line with the regulations. The provider ensured that daily records, care plans, risk assessments and contemporaneous records in relation to care delivery were detailed, individualised updated and reviewed regularly. This meant staff knew how to care for people in the service.”

Source location

Response from Care Quality Commission
Page 3 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Home disputes that its skin records were contradictory or misleading, stating that the terminology consistently described intact skin or a Grade 1 wound.

Verbatim wording from the response

“• We note that the Coroner found the Home’s notes contradictory and suggests that they were misleading. However, to clarify, the descriptions of ‘redness’, ‘sore’ and ‘skin intact’ are all consistent statements to describe skin that is not broken down. These descriptions are consistent with a Grade 1 pressure wound. A Grade 2 pressure wound is where the outer surface of the skin is damaged and the skin is broken down.”

Source location

Response from Mulberry Court Care Home
Page 2 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Existing care systems and processes are considered sufficient because implemented measures are described as robust, sustained and externally verified.

Verbatim wording from the response

“The Coroner raised concerns that issues may recur in the future. We wish to reassure the Coroner that the systems that have been put in place since Mr Nelson’s death are robust and the Company is fully committed to ensure that compliance is maintained. This has been verified by our external regulators.”

Source location

Response from Mulberry Court Care Home
Page 7 · response
Published 21 January 2026

Open published response

Other statements in published responses

These actions and other statements could not be clearly connected to one concern in this report.

Recipient-stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.6

  1. 1

    Embed learning from this case into practice.

    Stated by Care Quality CommissionStated in progressThe respondent said that this action was in progress when they made their response on 21 January 2026.
  2. 2

    Strengthen support for inspection teams by establishing a Specific Incident Progression Team to improve consistency in incident follow-up and enforcement alignment.

    Stated by Care Quality CommissionStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
  3. 3

    Contact relatives with the Coroner’s findings and actions taken, offering face-to-face meetings.

    Stated by Mulberry Healthcare LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
  4. 4

    Review care delivery independently, prepare a service improvement plan, and share it with the CQC and ICB.

    Stated by Mulberry Healthcare LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
  5. 5

    Complete clinical and medication competency assessments to confirm staff competence to run shifts.

    Stated by Mulberry Healthcare LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.
  6. 6

    Brief staff on the inquest findings, identified concerns, and actions taken to address them.

    Stated by Mulberry Healthcare LtdStated completedThe respondent said that this action was complete when they made their response on 21 January 2026.

Recipient positions A position is what a recipient says about a concern when they do not describe a specific action.4

  1. 1

    The death notification did not proceed to further review because it described an expected death within an end-of-life care pathway.

    Stated by Care Quality CommissionNo action considered necessaryThe respondent said that no further action was needed.
  2. 2

    The Home disputes that its care plan was inappropriate, citing subsequent improvement in the pressure area and healing observed by the GP.

    Stated by Mulberry Healthcare LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  3. 3

    The Home disputes that the pressure wounds were attributable to its care, noting wounds developed or worsened after admission to hospital.

    Stated by Mulberry Healthcare LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.
  4. 4

    The Home attributes impaired skin integrity and healing partly to comorbidities, poor nutrition, weight loss, incontinence and medication.

    Stated by Mulberry Healthcare LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Embed learning from this case into practice.

Verbatim wording from the response

“our regulatory responsibilities. We will continue to monitor the provider’s compliance with regulatory standards and ensure that learning from this case is embedded into practice. We remain committed to supporting improvements in patient safety and care quality across all services.”

Source location

Response from Care Quality Commission
Page 5 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Strengthen support for inspection teams by establishing a Specific Incident Progression Team to improve consistency in incident follow-up and enforcement alignment.

Verbatim wording from the response

“CQC have taken steps to strengthen support for inspection teams to ensure the Specific Incident process is consistently followed in future cases in line with CQC’s Specific Incident guidelines. To enhance our oversight of incident follow-up and ensure alignment with our enforcement powers, we have established a Specific Incident Progression Team (SIPT). This team supports inspection staff in meeting our responsibilities for incident follow-up and ensures alignment with our enforcement powers.”

Source location

Response from Care Quality Commission
Page 4 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Contact relatives with the Coroner’s findings and actions taken, offering face-to-face meetings.

Verbatim wording from the response

“2. Every service user’s relative was contacted and provided with details of the Coroner’s findings and informed of the action the Company was taking to address the Coroner’s concerns. Families were offered the opportunity to for face-to-face meetings.”

Source location

Response from Mulberry Court Care Home
Page 3 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Review care delivery independently, prepare a service improvement plan, and share it with the CQC and ICB.

Verbatim wording from the response

“We have undertaken a review of the care delivery at Mulberry Court Care Home. This was independently led by a Manager from one of other services. Following this review, we prepared a service improvement plan (SIP). A copy of the SIP is attached at Annex A. The SIP was shared with both the CQC and ICB.”

Source location

Response from Mulberry Court Care Home
Page 3 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Complete clinical and medication competency assessments to confirm staff competence to run shifts.

Verbatim wording from the response

“3. Clinical and medication competencies were carried out to ensure that staff were competent to run the shift.”

Source location

Response from Mulberry Court Care Home
Page 3 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent action was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

Brief staff on the inquest findings, identified concerns, and actions taken to address them.

Verbatim wording from the response

“1. All staff were briefed regarding the Inquest and the Coroner’s findings and made aware of the concerns identified and informed of the action the Company was taking to address the Coroner’s concerns.”

Source location

Response from Mulberry Court Care Home
Page 3 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The death notification did not proceed to further review because it described an expected death within an end-of-life care pathway.

Verbatim wording from the response

“Our National Customer Service Centre team received a statutory notification of death from Mulberry Court Care Home on 30 January 2025. This notification did not proceed for further review as the details within the notification stated the death was expected and was part of an end-of-life care pathway.”

Source location

Response from Care Quality Commission
Page 4 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Home disputes that its care plan was inappropriate, citing subsequent improvement in the pressure area and healing observed by the GP.

Verbatim wording from the response

“• Mr Nelson was reviewed by his GP on 16 December 2024, who reported that the pressure area was improving, with some areas of healing on the edges, suggesting that the plan of care was appropriate.”

Source location

Response from Mulberry Court Care Home
Page 2 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Home disputes that the pressure wounds were attributable to its care, noting wounds developed or worsened after admission to hospital.

Verbatim wording from the response

“• Following Mr Nelson’s first admission to NUH, Mr Nelson’s sacral area was not photographed by staff at NUH until 19.17 hours on 22 October 2024, nearly an hour and half after he left Mulhernry Court. At this point the records state that Mr Nelson had a Grade 2 pressure wound to their right buttock and SDTI T to the left buttock. A Grade 2 pressure wound and STDI can develop in under 1 hour in high-risk individuals (which Mr Nelson was), particularly if no pressure area relief is given, for example if he remained on a stretcher or trolley.”

Source location

Response from Mulberry Court Care Home
Page 2 · response
Published 21 January 2026

Open published response

Source evidence

How this respondent position was interpreted

PFD Monitor created a concise, searchable interpretation from the published response wording shown below.

PFD Monitor interpretation

The Home attributes impaired skin integrity and healing partly to comorbidities, poor nutrition, weight loss, incontinence and medication.

Verbatim wording from the response

“• As acknowledged by the Coroner, Mr Nelson had a number of comorbidities which impacted on his skin integrity and the healing process, including poor nutritional intake, weight loss, urinary and faecal incontinence (which resulted in more frequent dressing changes, lessening their efficacy), and prescribed medication.”

Source location

Response from Mulberry Court Care Home
Page 2 · response
Published 21 January 2026

Open published response
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Information checked against the published report and official responses · Data reviewed 7 Sep 2026 · About data quality and limitations

Data last updated 7 September 2026