PFD report

Victor Valentine Costello · Prevention of Future Deaths report

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Issued 14 Mar 2024•Teesside and Hartlepool

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
7

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 to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff
    Part of recurring concern: Unreliable communication of patient-care information between clinical staffPart of recurring concern: Unreliable communication of patients' nutritional requirementsPart of recurring concern: Unreliable management of nil-by-mouth restrictions
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.5

  1. Action

    Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.

    Stated by Stockton Care LimitedStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.
  2. Action

    Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.

    Stated by Stockton Care LimitedStated in progressThe respondent said that this action was in progress when they made their response on 19 March 2024.
  3. Action

    Implement an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.

    Stated by Stockton Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.

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 to effectively communicate nil-by-mouth and PEG-feeding concerns to care staff

Wider context from the report

“Mr Costello was nil by mouth and PEG fed. His family raised concerns that Mr Costello had told them he had been drinking water from the taps in his bathroom. Evidence was given at the inquest by the Nursing Home Manager that such concerns were communicated to all staff. However, further evidence given at the inquest showed that such communication was not effective (the nurse in charge and the two care assistants who were on duty on the morning Mr Costello was taken to hospital, all denied being aware of such concerns). ”

Is this part of a recurring concern?

Yes — Unreliable communication of patient-care information between clinical staff; Unreliable communication of patients' nutritional requirements; Unreliable management of nil-by-mouth restrictions.

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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

Maintain robust day and night handovers covering resident risks, complaints and concerns, with management oversight and audit monitoring.

Verbatim wording from the response

“We have made sure that effective and robust handovers take place between day and night staff to include explaining risks associated with | Home Manger- ████████ All nursing and senior staff, | Ongoing.”

Source location

Response from Stockton Care LTD
Page 1 · response
Published 19 March 2024

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

Ensure detailed risk assessments and care plans for residents receiving modified diets or fluids.

Verbatim wording from the response

“The management will monitor handovers as part of our regular audits. We are also making sure that for all residents who are on modified diet and fluids, their risk assessments and care plans are detailed and will be shared with next of kin to make sure all the information is correct. | ████████- Operations Director, will keep their record of our checks and any shortfalls will be addressed. | On going”

Source location

Response from Stockton Care LTD
Page 2 · response
Published 19 March 2024

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 an upgraded cloud-based electronic documentation system displaying residents’ risks, alerts and special instructions.

Verbatim wording from the response

“We are implementing an upgraded cloud based electronic documentation system where staff can easily look at each residents’ risks, alerts, and special instructions. | Chief Executive- ████████ Operation Director- ████████ Home Manger- ████████ All nursing and senior staff | The full implementation of the new electronic documentation system will be on 1st June 2024.”

Source location

Response from Stockton Care LTD
Page 1 · response
Published 19 March 2024

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

Schedule further staff meetings for employees who did not attend the 22 March 2024 meeting.

Verbatim wording from the response

“Actions | Responsible people | Time Scale We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. | Chief Executive- ████████ Operation Director- ████████ Home Manger- ████████ All nursing and senior staff | We had an all staff meeting on 22nd March 2024. We will schedule further meetings for those staff who did not attend.”

Source location

Response from Stockton Care LTD
Page 1 · response
Published 19 March 2024

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

Communicate the coroner’s concerns and effective communication requirements to all staff.

Verbatim wording from the response

“Actions | Responsible people | Time Scale We have communicated to all staff the coroner’s concern and the importance of effective communication including use of the electronic documentation system (see item below), daily handover sheets and verbal communication between shifts. | Chief Executive- ████████ Operation Director- ████████ Home Manger- ████████ All nursing and senior staff | We had an all staff meeting on 22nd March 2024. We will schedule further meetings for those staff who did not attend.”

Source location

Response from Stockton Care LTD
Page 1 · response
Published 19 March 2024

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.2

  1. 1

    Share modified-diet and fluid risk assessment and care plan information with residents’ next of kin.

    Stated by Stockton Care LimitedStated plannedThe respondent said that this action was planned when they made their response on 19 March 2024.
  2. 2

    Write to all service users and families about the organisation’s actions in response to the coroner’s concerns.

    Stated by Stockton Care LimitedStated completedThe respondent said that this action was complete when they made their response on 19 March 2024.

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

Share modified-diet and fluid risk assessment and care plan information with residents’ next of kin.

Verbatim wording from the response

“The management will monitor handovers as part of our regular audits. We are also making sure that for all residents who are on modified diet and fluids, their risk assessments and care plans are detailed and will be shared with next of kin to make sure all the information is correct. | ████████- Operations Director, will keep their record of our checks and any shortfalls will be addressed. | On going”

Source location

Response from Stockton Care LTD
Page 2 · response
Published 19 March 2024

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

Write to all service users and families about the organisation’s actions in response to the coroner’s concerns.

Verbatim wording from the response

“Taking into consideration of Coroner’s comments, we have written to all service users and families about our actions. | ████████ - Chief executive. | 08/04/2024”

Source location

Response from Stockton Care LTD
Page 2 · response
Published 19 March 2024

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