John Francis HOWLETT · Prevention of Future Deaths report

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Issued 6 Sep 2024•Manchester South

Published report and response evidence

This report’s concerns and statements found in recipients’ published responses. Statements are included even where no link to an individual concern is recorded. A link shows an evidence connection; it does not assign responsibility.

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Concerns
2

Raised in this report

Recipients
3

Named on the report

Responses found
3

Of 3 recipients

Stated actions
20

Described in responses

Recipients and published responses

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. 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
  2. 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 flowPart of recurring concern: Failure to provide timely hospital admission

Stated actions An action is something a recipient says it has done, is doing, or plans to do in response to a concern raised.20

  1. The Lakes Care Centre Limited

    Reduce reliance on agency staff below the level present during the resident’s stay.

  2. The Lakes Care Centre Limited

    Secure a qualified, experienced operational management team.

  3. The Lakes Care Centre Limited

    Meet monthly with the multi-agency concern panel to review improvement progress.

  4. The Lakes Care Centre Limited

    Use digital care records and daily hydration tracking to identify, escalate and remedy residents’ fluid-intake concerns.

  5. The Lakes Care Centre Limited

    Use surveys and face-to-face meetings to improve resident and family feedback.

  6. The Lakes Care Centre Limited

    De-register nursing services with the CQC.

  7. The Lakes Care Centre Limited

    Implement changes to recording and care-monitoring systems for earlier welfare and health escalation.

  8. The Lakes Care Centre Limited

    Conduct regular care and incident reviews and refer residents to appropriate support services.

  9. The Lakes Care Centre Limited

    Rebuild working relationships with local infection-prevention and contract-monitoring teams.

  10. The Lakes Care Centre Limited

    Monitor and respond to service-user, relative, visitor and professional feedback.

  11. The Lakes Care Centre Limited

    Commission a single GP service with weekly ward rounds for resident health observation.

  12. The Lakes Care Centre Limited

    Introduce an e-learning platform linking mandatory and developmental learning with policies, procedures and progress prompts.

  13. The Lakes Care Centre Limited

    Provide clearer direction and support to improve employee morale and first-time practice.

  14. The Lakes Care Centre Limited

    Deliver organisation-wide care and health training through meetings, individual sessions, e-learning and face-to-face training.

  15. Department of Health and Social Care

    Send the Regulation 28 report to the Care Quality Commission for consideration of regulatory action.

  16. Care Quality Commission

    Continue monitoring The Lakes Care Centre to identify whether concerns escalate and require further regulatory action.

  17. Care Quality Commission

    Seek to register the provider’s proposed registered manager as soon as possible.

  18. Care Quality Commission

    Take enforcement action in response to identified safety, risk-management and governance shortcomings at The Lakes Care Centre.

  19. Care Quality Commission

    Implement the Single Assessment Framework, including six evidence categories for flexible, ongoing provider assessment.

  20. Care Quality Commission

    Assess The Lakes Care Centre against safety, effectiveness and leadership requirements, identifying required improvements and regulatory breaches.

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

  1. Department of Health and Social Care

    No Safeguarding Adults Review was considered necessary because learning was identified for the care home, but not for wider partners.

    No action considered necessaryThe respondent said that no further action was needed.
  2. Care Quality Commission

    The reported emergency-department corridor wait caused by capacity pressures falls outside the regulator’s remit.

    Outside remitThe respondent said that this matter was outside its role or authority.
  3. Care Quality Commission

    Responsibility for addressing the emergency-department corridor wait is directed to the Secretary of State for Health and Social Care.

    Redirects responsibilityThe respondent said that another organisation was responsible for deciding or taking action.

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

Wider context from the report

“2. The evidence before the inquest indicated that the care home in question had been of concern in relation to the care offered to residents for some time. It was indicated that action plans were in place particularly in relation to safeguarding concerns given the vulnerability of residents. However despite those steps being in place and the concerns the systems were not in place at the care home to robustly monitor his nutritional status and fluid intake. He became increasingly frail with decreased physiological reserves as a consequence. ”

Is this part of a recurring concern?

Yes — Inadequate management of patients' nutrition and hydration needs.

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

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

Wider context from the report

“1. The inquest heard that on arrival at A and E at Tameside Hospital Mr Howlett spent 22 hours in a corridor despite suffering from an infection and the distress that this caused. The inquest was told that this was due to the demands on the department and the challenges of moving patients onto wards due to capacity issues. The inquest was told that this was not unique to that particular day or indeed to the hospital and was the picture across the country at that time. ”

Is this part of a recurring concern?

Yes — Failure to maintain safe hospital patient flow; Failure to provide timely hospital admission.

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

Reduce reliance on agency staff below the level present during the resident’s stay.

Verbatim wording from the response

“f) Reduce our reliance on ‘agency staff’ to a level that is lower than at the time of this residents stay. This helps us be confident in our employees/workers skills and performance. In addition, we have more day-to-day confidence that our employees are following our Core Values in everyday practice.”

Source location

Response from The Lakes Care Centre
Page 3 · response
Published 10 September 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

Secure a qualified, experienced operational management team.

Verbatim wording from the response

“We have since de-registered with CQC for Nursing Services. In addition, since September 2024 we have now managed to secure a full operational management team with both experience and qualifications to enable The Lakes to create reasonable, time focused and effective Action Plans for Improvement.”

Source location

Response from The Lakes Care Centre
Page 1 · response
Published 10 September 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

Meet monthly with the multi-agency concern panel to review improvement progress.

Verbatim wording from the response

“In addition to our internal improvement plans we have been working with the MAC Process (Multi Agency Concern) panel made up of professionals from a broad spectrum of disciplines. We meet monthly to review and assess progress to our improvement goals.”

Source location

Response from The Lakes Care Centre
Page 2 · response
Published 10 September 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

Use digital care records and daily hydration tracking to identify, escalate and remedy residents’ fluid-intake concerns.

Verbatim wording from the response

“c) The New Management Structure is working closely with senior carers about the ability of the Digital Care Record to assist in ensuring Residents Well Being and the Hydration Chart is a good example of this.”

Source location

Response from The Lakes Care Centre
Page 2 · response
Published 10 September 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

Use surveys and face-to-face meetings to improve resident and family feedback.

Verbatim wording from the response

“h) Improve resident and family feedback. From some initial surveys and face to face meetings, the feedback we are getting is that our service is more welcoming, and more caring. The facilities are described as outstanding and very homely.”

Source location

Response from The Lakes Care Centre
Page 3 · response
Published 10 September 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

De-register nursing services with the CQC.

Verbatim wording from the response

“We have since de-registered with CQC for Nursing Services. In addition, since September 2024 we have now managed to secure a full operational management team with both experience and qualifications to enable The Lakes to create reasonable, time focused and effective Action Plans for Improvement.”

Source location

Response from The Lakes Care Centre
Page 1 · response
Published 10 September 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 changes to recording and care-monitoring systems for earlier welfare and health escalation.

Verbatim wording from the response

“The new Manager and myself have been busy implementing changes to our in-house recording systems and care monitoring systems to ensure we identify and action any changes in residents’ welfare and health at the earliest opportunity.”

Source location

Response from The Lakes Care Centre
Page 1 · response
Published 10 September 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

Conduct regular care and incident reviews and refer residents to appropriate support services.

Verbatim wording from the response

“This is now showing major improvement in managing and providing good outcomes for our residents whilst looking at a process of continual improvement through regular care reviews, incident reviews and referral on to appropriate services for support in providing a timely and safer and more effective service to our residents.”

Source location

Response from The Lakes Care Centre
Page 2 · response
Published 10 September 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

Rebuild working relationships with local infection-prevention and contract-monitoring teams.

Verbatim wording from the response

“e) We have begun to nurture again our relationship with the local Infection Prevention Teams and Contract Monitoring Teams to ‘move’ forward on our performance on a day-to-day basis and improve the quality of care and support and outcomes for our residents.”

Source location

Response from The Lakes Care Centre
Page 3 · response
Published 10 September 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

Monitor and respond to service-user, relative, visitor and professional feedback.

Verbatim wording from the response

“We monitor and respond to Service User Feedback, Relatives/Visitor feedback and professional feedback both positive and negative.”

Source location

Response from The Lakes Care Centre
Page 2 · response
Published 10 September 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

Commission a single GP service with weekly ward rounds for resident health observation.

Verbatim wording from the response

“In November 2024 a new single GP service has been commissioned and we hope this will improve communication and clinical observation of our residents including weekly ‘ward rounds’ to identify early sign of improvement or deterioration in their health.”

Source location

Response from The Lakes Care Centre
Page 1 · response
Published 10 September 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

Introduce an e-learning platform linking mandatory and developmental learning with policies, procedures and progress prompts.

Verbatim wording from the response

“b) We are introducing (Sep 24) a new E Learning platform which enables employees to access mandatory and developmental learning with associated policy and procedures attached as part of that learning. It also provides much better visibility of employee learning progress and prompts employees and managers of the expectations in a timely manner to maximise attendance and outcomes.”

Source location

Response from The Lakes Care Centre
Page 2 · response
Published 10 September 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

Provide clearer direction and support to improve employee morale and first-time practice.

Verbatim wording from the response

“g) Improve employee morale with clearer direction and support to get things right first time. Feedback from employees has been excellent since we took over and they are saying they feel more supported and valued as a team. This is an ongoing management focus.”

Source location

Response from The Lakes Care Centre
Page 3 · response
Published 10 September 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

Deliver organisation-wide care and health training through meetings, individual sessions, e-learning and face-to-face training.

Verbatim wording from the response

“a) Started all training from ‘scratch’ to ensure all employees get the same level and undertraining of what is required in all care and health matters. This is via Team meetings, individual 1:1 sessions, E Learning and Face to Face training.”

Source location

Response from The Lakes Care Centre
Page 2 · response
Published 10 September 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

Send the Regulation 28 report to the Care Quality Commission for consideration of regulatory action.

Verbatim wording from the response

“The Care Quality Commission (CQC) has also been sent a copy of this Regulation 28 report and will be issuing a response. The CQC regulate providers of health and social care services to ensure they are providing safe and effective care, and will consider if any regulatory action needs to be taken.”

Source location

Response from DHSC
Page 2 · response
Published 10 September 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

Continue monitoring The Lakes Care Centre to identify whether concerns escalate and require further regulatory action.

Verbatim wording from the response

“The coroner noted in this regulation 28 report that despite action plans being in place in relation to safeguarding concerns, systems were not in place at the care home to robustly monitor Mr Howlett’s nutritional status and fluid intake. Our assessment finding indicated there continued to be some areas for improvement shortly after Mr Howlett’s death, but that action was being implemented and embedded at that time. Enforcement action was taken in response to these findings and CQC continue to monitor the service to identify if concerns around the service are escalated and require further action.”

Source location

Response from CQC
Page 6 · response
Published 10 September 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

Seek to register the provider’s proposed registered manager as soon as possible.

Verbatim wording from the response

“At the time of our visit there was no registered manager in post and there have been changes to the home manager. Upon the provider identifying a suitable candidate for the registered manager role, an application has been accepted by CQC’s registration team and we will seek to register this individual as soon as possible.”

Source location

Response from CQC
Page 7 · response
Published 10 September 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

Take enforcement action in response to identified safety, risk-management and governance shortcomings at The Lakes Care Centre.

Verbatim wording from the response

“The coroner noted in this regulation 28 report that despite action plans being in place in relation to safeguarding concerns, systems were not in place at the care home to robustly monitor Mr Howlett’s nutritional status and fluid intake. Our assessment finding indicated there continued to be some areas for improvement shortly after Mr Howlett’s death, but that action was being implemented and embedded at that time. Enforcement action was taken in response to these findings and CQC continue to monitor the service to identify if concerns around the service are escalated and require further action.”

Source location

Response from CQC
Page 6 · response
Published 10 September 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 the Single Assessment Framework, including six evidence categories for flexible, ongoing provider assessment.

Verbatim wording from the response

“On 6 February 2024 CQC’s Operations Network in the North region went live with our new Single Assessment Framework. This approach covers all sectors, service types and levels and the five key questions remain central to this approach. However, the previous key lines of enquiry (KLOEs) and prompts have been replaced with new ‘quality statements’. The quality statements are described as ‘we statements’ as they have been written from a provider’s perspective to help them understand what we expect of them. They draw on previous work developed with Think Local Act Personal (TLAP), National Voices and the Coalition for Collaborative Care on Making it Real. They set clear expectations of providers, based on people’s experiences and the standards of care they expect.”

Source location

Response from CQC
Page 2 · response
Published 10 September 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

Assess The Lakes Care Centre against safety, effectiveness and leadership requirements, identifying required improvements and regulatory breaches.

Verbatim wording from the response

“An assessment of The Lakes Care Centre was commenced on 22 April 2024 following concerns in relation to the care and support people were receiving. The key questions of ‘Is the service safe?’, ‘Is the service effective’ and ‘Is the service well led?’ were reviewed and the overall rating for these key questions and the service overall was ‘requires improvement’. At the time of this assessment The Lakes Care Centre had recently stopped operating as a nursing home but was still registered to deliver the regulated activity of ‘Treatment for Disease, Disorder or Injury’. The provider was asked to submit a notification to deregister from this regulated activity at the location and this was completed on 26 September 2024. The Lakes Care Centre continues to be registered for the regulated activity of ‘Accommodation for people requiring nursing or personal care’.”

Source location

Response from CQC
Page 4 · response
Published 10 September 2024

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

No Safeguarding Adults Review was considered necessary because learning was identified for the care home, but not for wider partners.

Verbatim wording from the response

“It is good practice for a local authority’s Safeguarding Adults Board (SAB) to work with coroners. You may have already contacted the local SAB about whether they have considered Safeguarding Adults Review (SAR). However separately DHSC officials reached out to Tameside SAB.”

Source location

Response from DHSC
Page 2 · response
Published 10 September 2024

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 reported emergency-department corridor wait caused by capacity pressures falls outside the regulator’s remit.

Verbatim wording from the response

“We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr Howlett spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit. We note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.”

Source location

Response from CQC
Page 4 · response
Published 10 September 2024

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

Responsibility for addressing the emergency-department corridor wait is directed to the Secretary of State for Health and Social Care.

Verbatim wording from the response

“We have given careful consideration to this point and have come to the conclusion that the concerns identified, namely, that Mr Howlett spent 22 hours in a corridor despite suffering from a chest infection due to demands on the department and capacity issues, a situation not unique to that particular day or hospital, sits outside of CQC remit. We note that this report has also been sent to the Secretary of State for Health and Social Care and believe they will be of greater assistance in addressing this aspect of your concerns.”

Source location

Response from CQC
Page 4 · response
Published 10 September 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