PFD report

John Francis HOWLETT · Prevention of Future Deaths report

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Issued 6 Sep 2024•Manchester South

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: 2
Recipients: 3
Responses found: 3
Stated actions: 20

Recipients and published responses

Care Quality CommissionResponse found Department of Health and Social CareResponse found The Lakes Care CentreNo response found

Source document

Full report text

This is the full text from the original published report.

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Investigation and inquest

On 6th February 2024 I commenced an investigation into the death of John Francis HOWLETT. The investigation concluded on the 13th August 2024 and the conclusion was one of Narrative: Died from exacerbation of chronic obstructive pulmonary disease contributed to by frailty due to dehydration and poor nutritional status. The medical cause of death was 1a) Infective exacerbation of chronic obstructive pulmonary disease II) Frailty

Concerns and recipient responses

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

Concerns raised2

Lack of robust monitoring of care-home residents' nutritional status and fluid intake
Part of recurring concern: Inadequate management of patients' nutrition and hydration needs
Failure to move patients from emergency departments onto wards in a timely manner due to capacity constraints
Part of recurring concern: Failure to maintain safe hospital patient flow Part of recurring concern: Failure to provide timely hospital admission

Responses linked to these concerns

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

Actions described in response 5

Action
Use digital care records and daily hydration tracking to identify, escalate and remedy residents’ fluid-intake concerns.
Stated by The Lakes Care Centre LimitedStated completed
Action
Implement changes to recording and care-monitoring systems for earlier welfare and health escalation.
Stated by The Lakes Care Centre LimitedStated in progress
Action
Continue monitoring The Lakes Care Centre to identify whether concerns escalate and require further regulatory action.
Stated by Care Quality CommissionStated completed

Respondent positions 3

Position
No Safeguarding Adults Review was considered necessary because learning was identified for the care home, but not for wider partners.
Stated by Department of Health and Social CareNo action considered necessary

Other statements in published responses

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

Recipient-stated actions 15

1
Reduce reliance on agency staff below the level present during the resident’s stay.
Stated by The Lakes Care Centre LimitedStated planned
2
Secure a qualified, experienced operational management team.
Stated by The Lakes Care Centre LimitedStated completed
3
Meet monthly with the multi-agency concern panel to review improvement progress.
Stated by The Lakes Care Centre LimitedStated in progress
4
Use surveys and face-to-face meetings to improve resident and family feedback.
Stated by The Lakes Care Centre LimitedStated completed
5
De-register nursing services with the CQC.
Stated by The Lakes Care Centre LimitedStated completed
6
Conduct regular care and incident reviews and refer residents to appropriate support services.
Stated by The Lakes Care Centre LimitedStated in progress
7
Rebuild working relationships with local infection-prevention and contract-monitoring teams.
Stated by The Lakes Care Centre LimitedStated in progress
8
Monitor and respond to service-user, relative, visitor and professional feedback.
Stated by The Lakes Care Centre LimitedStated completed
9
Commission a single GP service with weekly ward rounds for resident health observation.
Stated by The Lakes Care Centre LimitedStated completed
10
Introduce an e-learning platform linking mandatory and developmental learning with policies, procedures and progress prompts.
Stated by The Lakes Care Centre LimitedStated in progress
11
Provide clearer direction and support to improve employee morale and first-time practice.
Stated by The Lakes Care Centre LimitedStated in progress
12
Deliver organisation-wide care and health training through meetings, individual sessions, e-learning and face-to-face training.
Stated by The Lakes Care Centre LimitedStated in progress
13
Send the Regulation 28 report to the Care Quality Commission for consideration of regulatory action.
Stated by Department of Health and Social CareStated completed
14
Seek to register the provider’s proposed registered manager as soon as possible.
Stated by Care Quality CommissionStated planned
15
Implement the Single Assessment Framework, including six evidence categories for flexible, ongoing provider assessment.
Stated by Care Quality CommissionStated completed

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

Published report and response evidence

Recipients and published responses

Report evidence summary

Concerns raised2

Lack of robust monitoring of care-home residents' nutritional status and fluid intake

Failure to move patients from emergency departments onto wards in a timely manner due to capacity constraints

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

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

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.15

Actions described in response 5

Respondent positions 3

Recipient-stated actions 15