PFD report

Daphne Cherry · Prevention of Future Deaths report

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Issued 13 Mar 2017•Gloucestershire

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.

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Concerns
1

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
5

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 raised1

  1. Failure of care home staff to identify when medical concerns require escalation and medical review
    Part of recurring concern: Unreliable escalation by care staff for required medical attention
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.4

  1. Action

    Cascade deterioration-recognition training to shift leaders and remaining care-home staff, reinforcing the principles through individual supervision.

    Stated by Care UK Community Partnerships LtdStated plannedThe respondent said that this action was planned when they made their response on 24 March 2017.
  2. Action

    Audit staff responses to unwell residents through management discussions, walkarounds and out-of-hours escalation oversight.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.
  3. Action

    Train the home manager, deputy manager and unit leaders in early recognition of sick and deteriorating residents.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.

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

Failure of care home staff to identify when medical concerns require escalation and medical review

Wider context from the report

“(1) Whether staff at the Care Home are able to identify when a medical concern should be escalated and a medical review sought. ”

Is this part of a recurring concern?

Yes — Unreliable escalation by care staff for required medical attention.

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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

Cascade deterioration-recognition training to shift leaders and remaining care-home staff, reinforcing the principles through individual supervision.

Verbatim wording from the response

“Alongside this, and in order to augment the training, the unit leaders have been specifically tasked, in conjunction with the Care UK governance team, with cascading the principles of the”

Source location

Response from Care UK
Page 1 · response
Published 24 March 2017

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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

Audit staff responses to unwell residents through management discussions, walkarounds and out-of-hours escalation oversight.

Verbatim wording from the response

“We recognise that it is important to also monitor the efficacy of training and knowledge-building, and this is the responsibility of the home manager and deputy home manager. One of them will be on duty at any one time, including evenings and weekends. There is therefore 24/7 management coverage. As we mentioned above, there is also always a nurse on duty.”

Source location

Response from Care UK
Page 2 · response
Published 24 March 2017

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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

Train the home manager, deputy manager and unit leaders in early recognition of sick and deteriorating residents.

Verbatim wording from the response

“As a preliminary point, Sandfields employs a number of registered nurses and there is always at least one on duty at any given time. As the Coroner will be aware, nurses undergo extensive professional training which would cover recognition of the clinical symptoms exhibited by a deteriorating resident. Care UK has nonetheless taken further action both to supplement this professional knowledge of our nurses, and also to train the rest of the Sandfields staff (including those who are non-clinically trained) in recognising deteriorating residents.”

Source location

Response from Care UK
Page 1 · response
Published 24 March 2017

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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

Book all shift leaders onto forthcoming Care Home Support training in recognising sick and deteriorating residents.

Verbatim wording from the response

“We are awaiting further dates for training sessions to be released by the Care Home Support team and, as soon as they have been made available then all shift leaders will be booked onto upcoming sessions. We expect the dates to be released in the next couple of weeks.”

Source location

Response from Care UK
Page 1 · response
Published 24 March 2017

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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.1

  1. 1

    Maintain an SBAR prompt beside telephones to support staff communicating residents’ clinical information to medical services.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 24 March 2017.

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

Maintain an SBAR prompt beside telephones to support staff communicating residents’ clinical information to medical services.

Verbatim wording from the response

“In terms of the training itself, it includes an escalation numbering system to alert staff to the seriousness of the resident’s condition, otherwise known as the ‘National Early Warning Score’, (or ‘NEWS’). This provides an algorithm by which six physical parameters are measured and given a score. The overall score then provides staff with a clear indication as to what type of response is required to each clinical scenario, so whether this is a call to the 111 service, a GP or an ambulance.”

Source location

Response from Care UK
Page 2 · response
Published 24 March 2017

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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