PFD report

Lilian SHEARING · Prevention of Future Deaths report

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Issued 14 Sep 2022•Lincolnshire

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
3

Raised in this report

Recipients
1

Named on the report

Responses found
1

Of 1 recipient

Stated actions
12

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 raised3

  1. Failure to undertake risk assessments for poor fluid and nutritional intake
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needs
  2. Failure to record fluid intake accurately
    Part of recurring concern: Failure to reliably monitor patient fluid balancePart of recurring concern: Unreliable recording of fluid balance information
  3. Lack of policies governing risks from poor fluid and nutritional intake
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needs
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

    Embed admission safeguards requiring risk assessments, daily charts, documented communications, timely referrals, and updates to residents and representatives.

    Stated by TanglewoodStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2022.
  2. Action

    Maintain ongoing staff training on nutrition, hydration, and responding to declining food or fluid intake.

    Stated by TanglewoodStated in progressThe respondent said that this action was in progress when they made their response on 5 October 2022.
  3. Action

    Review and amend the Nutrition and Hydration policy to cover intake recording, refusals, fluid targets, and discussions with clinicians and families.

    Stated by TanglewoodStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.

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

  1. Position

    Staff cannot force residents to take food or fluids when they refuse, but must record the refusal and intake.

    Stated by TanglewoodUnable to actThe respondent said that a constraint prevented them from taking the relevant 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

Failure to undertake risk assessments for poor fluid and nutritional intake

Wider context from the report

“Upon admission on 11th July 2019 to your care home it was recorded at handover the deceased had a poor fluid intake. Despite this no risk assessment was undertaken. Omissions were also made from the fluid intake chart. It was conceded at Inquest today by your regional manager that the deceased's fluid intake was approximately 25% of where it should have been before her admission to hospital on 23rd August 2019 due to dehydration. Policies/assessments were clearly not in place to cover this eventuality. What are your current policies re risk assessments for fluid and nutritional intake? ”

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 record fluid intake accurately

Wider context from the report

“Upon admission on 11th July 2019 to your care home it was recorded at handover the deceased had a poor fluid intake. Despite this no risk assessment was undertaken. Omissions were also made from the fluid intake chart. It was conceded at Inquest today by your regional manager that the deceased's fluid intake was approximately 25% of where it should have been before her admission to hospital on 23rd August 2019 due to dehydration. Policies/assessments were clearly not in place to cover this eventuality. What are your current policies re risk assessments for fluid and nutritional intake? ”

Is this part of a recurring concern?

Yes — Failure to reliably monitor patient fluid balance; Unreliable recording of fluid balance information.

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

Lack of policies governing risks from poor fluid and nutritional intake

Wider context from the report

“Upon admission on 11th July 2019 to your care home it was recorded at handover the deceased had a poor fluid intake. Despite this no risk assessment was undertaken. Omissions were also made from the fluid intake chart. It was conceded at Inquest today by your regional manager that the deceased's fluid intake was approximately 25% of where it should have been before her admission to hospital on 23rd August 2019 due to dehydration. Policies/assessments were clearly not in place to cover this eventuality. What are your current policies re risk assessments for fluid and nutritional intake? ”

Is this part of a recurring concern?

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

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

Embed admission safeguards requiring risk assessments, daily charts, documented communications, timely referrals, and updates to residents and representatives.

Verbatim wording from the response

“• Ensure that any risk assessments required are completed to ensure minimal risk to the person”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 2 · response
Published 5 October 2022

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

Maintain ongoing staff training on nutrition, hydration, and responding to declining food or fluid intake.

Verbatim wording from the response

“Training It is three years since Mrs LS death and the monitoring and auditing processes within all Tanglewood homes has been enhanced significantly. Throughout the pandemic, work has been ongoing to continue to provide essential training. A new platform for e-learning was introduced which enabled team members, both newly employed and established, to access ongoing training throughout this period. There has been a continued focus on the importance of nutrition and hydration and how we support residents in all stages of their later life and what we can do in the event of the individual declining adequate nutritional and fluid intake required to sustain life. A care plan manager has been employed to oversee the care plans and content in all homes ensuring the standard of documentation is consistent, this person also provides training to all care teams to ensure the process is understood.”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022

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

Review and amend the Nutrition and Hydration policy to cover intake recording, refusals, fluid targets, and discussions with clinicians and families.

Verbatim wording from the response

“Policy & Procedure We have reviewed the content of the Nutrition & Hydration policy and amended the content to include current practice of monitoring and recording all intake (see appendix 1), how we support the resident who may be reluctant to accept food and fluids especially at end of life, and the importance of recording if a resident declines assistance or intervention. What we do if a residents daily fluid target appears excessive and is not consistently achieved over a 7-day period and how we manage and record the discussions with the GP and family members in relation to this.”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022

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 a two-stage admissions process requiring key documentation within 24 hours and a live care plan within seven days.

Verbatim wording from the response

“We have set up the admission process over two time frames the first being 24-hours to complete key documents, this can be done using a pre-assessment document and additional information from family members – a nutrition & hydration assessment is included – and the formulation of the remainder of the care plan within 7-days as this is a live document that will continually evolve. In addition to written referrals or transfer documents, residents and their families are actively involved in providing information which enables us to provide consistent, holistic care for the individual.”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022

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 face-to-face staff training on care documentation and recording offered or declined nutrition and fluids.

Verbatim wording from the response

“• Ongoing face-to-face staff training within the homes to embed the importance of maintaining records and documentation to provide evidence of care provided”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 2 · response
Published 5 October 2022

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

Staff cannot force residents to take food or fluids when they refuse, but must record the refusal and intake.

Verbatim wording from the response

“• Ongoing staff training within the homes to ensure that all nutritional and fluid intake is recorded even if declined as we are unable to force residents to take food & fluids if they refuse”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 2 · response
Published 5 October 2022

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.7

  1. 1

    Disseminate the submitted information pack to all Tanglewood homes.

    Stated by TanglewoodStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  2. 2

    Provide a Nutrition and Fluid Information Folder in each home for team access and ongoing updates.

    Stated by TanglewoodStated plannedThe respondent said that this action was planned when they made their response on 5 October 2022.
  3. 3

    Implement daily clinical oversight and operational reporting across all homes, with management review and tracked follow-up actions.

    Stated by TanglewoodStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  4. 4

    Enhance monitoring and auditing processes across all homes, with action plans followed through to verification.

    Stated by TanglewoodStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  5. 5

    Employ a care plan manager to oversee documentation standards and train care teams on the process.

    Stated by TanglewoodStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  6. 6

    Provide an e-learning platform enabling new and established staff to access ongoing training.

    Stated by TanglewoodStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.
  7. 7

    Implement monthly Resident of the Day records and daily management sign-off to improve family communication and document follow-up.

    Stated by TanglewoodStated completedThe respondent said that this action was complete when they made their response on 5 October 2022.

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

Disseminate the submitted information pack to all Tanglewood homes.

Verbatim wording from the response

“Shared information All Tanglewood homes have received the information pack that has been submitted to the coroner as evidence of the progress that has been made and sustained during the past 3-years”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 2 · response
Published 5 October 2022

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 Nutrition and Fluid Information Folder in each home for team access and ongoing updates.

Verbatim wording from the response

“• The provision of a Nutrition & Fluid Information Folder for each home which will be included in home meeting discussion and available for team members to access for future information, this will be added to as we move forward”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 2 · response
Published 5 October 2022

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 daily clinical oversight and operational reporting across all homes, with management review and tracked follow-up actions.

Verbatim wording from the response

“Daily oversight – all homes Each Tanglewood home completes a daily clinical oversight and operational report, this has been developed and implemented during the past year. It gives the Directors a complete overview of all allocated services, the documents are saved down each day and reviewed by the registered manager of the home and the regional manager, with actions carried forward to ensure nothing is missed (An example copy of this has been attached as Appendix 2).”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022

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

Enhance monitoring and auditing processes across all homes, with action plans followed through to verification.

Verbatim wording from the response

“Training It is three years since Mrs LS death and the monitoring and auditing processes within all Tanglewood homes has been enhanced significantly. Throughout the pandemic, work has been ongoing to continue to provide essential training. A new platform for e-learning was introduced which enabled team members, both newly employed and established, to access ongoing training throughout this period. There has been a continued focus on the importance of nutrition and hydration and how we support residents in all stages of their later life and what we can do in the event of the individual declining adequate nutritional and fluid intake required to sustain life. A care plan manager has been employed to oversee the care plans and content in all homes ensuring the standard of documentation is consistent, this person also provides training to all care teams to ensure the process is understood.”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022

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

Employ a care plan manager to oversee documentation standards and train care teams on the process.

Verbatim wording from the response

“Training It is three years since Mrs LS death and the monitoring and auditing processes within all Tanglewood homes has been enhanced significantly. Throughout the pandemic, work has been ongoing to continue to provide essential training. A new platform for e-learning was introduced which enabled team members, both newly employed and established, to access ongoing training throughout this period. There has been a continued focus on the importance of nutrition and hydration and how we support residents in all stages of their later life and what we can do in the event of the individual declining adequate nutritional and fluid intake required to sustain life. A care plan manager has been employed to oversee the care plans and content in all homes ensuring the standard of documentation is consistent, this person also provides training to all care teams to ensure the process is understood.”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022

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 an e-learning platform enabling new and established staff to access ongoing training.

Verbatim wording from the response

“Training It is three years since Mrs LS death and the monitoring and auditing processes within all Tanglewood homes has been enhanced significantly. Throughout the pandemic, work has been ongoing to continue to provide essential training. A new platform for e-learning was introduced which enabled team members, both newly employed and established, to access ongoing training throughout this period. There has been a continued focus on the importance of nutrition and hydration and how we support residents in all stages of their later life and what we can do in the event of the individual declining adequate nutritional and fluid intake required to sustain life. A care plan manager has been employed to oversee the care plans and content in all homes ensuring the standard of documentation is consistent, this person also provides training to all care teams to ensure the process is understood.”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022

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 monthly Resident of the Day records and daily management sign-off to improve family communication and document follow-up.

Verbatim wording from the response

“We have improved communication with family members by completing Resident of the Day records – this ensures we are contacting next of kin/POA to discuss the individuals wellbeing each month in line with this process. Changes to a person’s health is communicated to the family as soon as it is identified with additional information being added to the care plan. GP referrals are made through direct contact with the surgery or through Ask My GP.”

Source location

Response from Tanglewood Cloverleaf Care Home
Page 1 · response
Published 5 October 2022

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