PFD report

Noreen Porter · Prevention of Future Deaths report

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Issued 22 Nov 2014•Birmingham and Solihull

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
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
6

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. Failure to undertake CPR during an emergency
  2. Lack of a process ensuring resuscitation during emergencies
    Part of recurring concern: Unreliable resuscitation preparedness and response during cardiac arrest
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.3

  1. Action

    Arrange refresher CPR training for delivery across the home.

    Stated by Ardenlea Grove Nursing HomeStated in progressThe respondent said that this action was in progress when they made their response on 22 December 2014.
  2. Action

    Reissue resuscitation and choking policies to all staff.

    Stated by Ardenlea Grove Nursing HomeStated completedThe respondent said that this action was complete when they made their response on 22 December 2014.
  3. Action

    Conduct focused supervision for all nursing staff on CPR policy and when CPR must commence.

    Stated by Ardenlea Grove Nursing HomeStated completedThe respondent said that this action was complete when they made their response on 22 December 2014.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.1

  1. Position

    Existing policies and procedures appropriately direct staff to commence CPR during emergencies; the incident resulted from those procedures not being followed.

    Stated by Ardenlea Grove Nursing HomeExisting arrangements considered sufficientThe respondent said that existing arrangements were sufficient, so no further action was needed.

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 undertake CPR during an emergency

Wider context from the report

“(1) No CPR was undertaken by the staff when the deceased collapsed. (2) There appears to be no process or procedure in place to ensure resuscitation is undertaken when an emergency occurs ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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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. Response links show a clear evidence connection; they do not assign responsibility.

PFD Monitor interpretation

Lack of a process ensuring resuscitation during emergencies

Wider context from the report

“(1) No CPR was undertaken by the staff when the deceased collapsed. (2) There appears to be no process or procedure in place to ensure resuscitation is undertaken when an emergency occurs ”

Is this part of a recurring concern?

Yes — Unreliable resuscitation preparedness and response during cardiac arrest.

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

Arrange refresher CPR training for delivery across the home.

Verbatim wording from the response

“Since this incident, the home manager at Ardenlea Grove has carried out the following steps to ensure all staff are aware of Bupa's policy and the steps that they must take in a similar situation and to learn the lessons from this tragic incident:”

Source location

2014-0550-Response-by-Bupa
Page 2 · response
Published 22 December 2014

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

Reissue resuscitation and choking policies to all staff.

Verbatim wording from the response

“Since this incident, the home manager at Ardenlea Grove has carried out the following steps to ensure all staff are aware of Bupa's policy and the steps that they must take in a similar situation and to learn the lessons from this tragic incident:”

Source location

2014-0550-Response-by-Bupa
Page 2 · response
Published 22 December 2014

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

Conduct focused supervision for all nursing staff on CPR policy and when CPR must commence.

Verbatim wording from the response

“Since this incident, the home manager at Ardenlea Grove has carried out the following steps to ensure all staff are aware of Bupa's policy and the steps that they must take in a similar situation and to learn the lessons from this tragic incident:”

Source location

2014-0550-Response-by-Bupa
Page 2 · response
Published 22 December 2014

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 policies and procedures appropriately direct staff to commence CPR during emergencies; the incident resulted from those procedures not being followed.

Verbatim wording from the response

“In the circumstances, in relation to your two areas of concern:”

Source location

2014-0550-Response-by-Bupa
Page 2 · response
Published 22 December 2014

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.3

  1. 1

    Cascade key messages and learning to other Bupa homes and use them in ongoing training.

    Stated by Ardenlea Grove Nursing HomeStated in progressThe respondent said that this action was in progress when they made their response on 22 December 2014.
  2. 2

    Share the report and response with operational management teams across Bupa homes.

    Stated by Ardenlea Grove Nursing HomeStated completedThe respondent said that this action was complete when they made their response on 22 December 2014.
  3. 3

    Provide a suction machine on each nursing-home floor by ordering and installing two additional machines.

    Stated by Ardenlea Grove Nursing HomeStated completedThe respondent said that this action was complete when they made their response on 22 December 2014.

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 key messages and learning to other Bupa homes and use them in ongoing training.

Verbatim wording from the response

“In order to help our staff to learn the lessons from this tragic incident, your report and this response has been shared with our operational management teams so that the key”

Source location

2014-0550-Response-by-Bupa
Page 2 · response
Published 22 December 2014

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

Share the report and response with operational management teams across Bupa homes.

Verbatim wording from the response

“In order to help our staff to learn the lessons from this tragic incident, your report and this response has been shared with our operational management teams so that the key”

Source location

2014-0550-Response-by-Bupa
Page 2 · response
Published 22 December 2014

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

Provide a suction machine on each nursing-home floor by ordering and installing two additional machines.

Verbatim wording from the response

“• Two more suction machines have been ordered so that there is now a machine on each floor of the nursing home. We appreciate that this was raised by the deceased's family during the inquest and I understand that the conclusion was that suction was unlikely to have altered the outcome for Mrs Porter in these circumstances. Nevertheless this case has caused the management team of Ardenlea Grove to reappraise all the procedures and processes for life support in place in the home and it was concluded that having a suction machine available on each floor was appropriate based on the assessed risks and needs of the resident population. These are now in place.”

Source location

2014-0550-Response-by-Bupa
Page 2 · response
Published 22 December 2014

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