PFD report

John Francis GREGORY · Prevention of Future Deaths report

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Issued 20 Mar 2020•Inner North London

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
9

Raised in this report

Recipients
4

Named on the report

Responses found
1

Of 4 recipients

Stated actions
15

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 raised9

  1. Failure to escalate and respond to prolonged inadequate fluid intake
    Part of recurring concern: Inadequate management of patients' nutrition and hydration needs
  2. Failure to provide bedtime arrangements based on patients’ needs rather than nursing routine
    Part of recurring concern: Failure to provide fundamental personal care and welfare
  3. Failure to secure patients safely in wheelchairs
    Part of recurring concern: Unsafe moving and handling of patients
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.11

  1. Action

    Roll out Restore2 deterioration monitoring, placing records in care plans and requiring monthly nursing updates.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 9 April 2020.
  2. Action

    Disseminate wheelchair-safety guidance through laminated copies at nurses’ stations and copies in relevant resident care-plan folders.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 9 April 2020.
  3. Action

    Provide full-group refresher training on wheelchair safety, appropriate dressing, oral-fluid encouragement and updated welfare-check documentation after restrictions are lifted.

    Stated by Care UK Community Partnerships LtdStated plannedThe respondent said that this action was planned when they made their response on 9 April 2020.

Respondent positions A position is what a recipient says about a concern when it does not describe a specific action.2

  1. Position

    The incident occurred on arrival at Muriel Street, not during hospital readmission, and the resident was neither in public nor unresponsive.

    Stated by Care UK Community Partnerships LtdDisputes the concernThe respondent disagreed with part of the concern or the basis for it.

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 escalate and respond to prolonged inadequate fluid intake

Wider context from the report

“4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia. On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm. The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this. His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him. This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat. ”

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 provide bedtime arrangements based on patients’ needs rather than nursing routine

Wider context from the report

“1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff. On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet; on more than one occasion his family found him in wet bedclothes; and he was put to bed at 7.30pm to fit in with nursing routine. ”

Is this part of a recurring concern?

Yes — Failure to provide fundamental personal care and welfare.

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 secure patients safely in wheelchairs

Wider context from the report

“3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff. He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself. ”

Is this part of a recurring concern?

Yes — Unsafe moving and handling of patients.

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 provide adequate clothing for patients unable to dress themselves

Wider context from the report

“3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff. He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 encourage patients to drink or eat when intake is inadequate

Wider context from the report

“4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia. On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm. The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this. His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him. This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 provide consistent toileting and continence care

Wider context from the report

“1. Whilst the sister in charge of Evergreen plainly led from the front and expected the highest standards, these were not always maintained by every member of staff. On one occasion, a member of staff refused Mr Gregory’s family assistance to take him to the toilet; on more than one occasion his family found him in wet bedclothes; and he was put to bed at 7.30pm to fit in with nursing routine. ”

Is this part of a recurring concern?

Yes — Unsafe continence care and management.

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 consistently encourage sufficient drinking and eating

Wider context from the report

“2. His oral fluid intake was considered by Evergreen Ward, and steps were taken to address this, but the intake recorded on his charts demonstrate that it remained too low. Maintaining sufficient fluid intake was a challenge, but there is the possibility that not every member of staff encouraged him to drink and eat in the way the sister in charge did. ”

Is this part of a recurring concern?

No recurring-concern membership is currently published.

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 monitor patients in communal areas

Wider context from the report

“3. On the day he was readmitted to hospital from Muriel Street, Mr Gregory’s family found him slumped unconscious in a public area of the home, a fact unnoticed by any member of staff. He was not properly strapped in to a wheelchair, slipping down because his feet were not on the foot rests. He was cold and inadequately dressed, with his shirt undone and not wearing socks. By then Mr Gregory was not capable of dressing himself. ”

Is this part of a recurring concern?

Yes — Unreliable patient observation arrangements.

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

Inaccurate recording of patients’ fluid intake

Wider context from the report

“4. Mr Gregory’s oral fluid intake was also too low at Muriel Street, a nursing home specialising in the care of those with dementia. On his last day at the home, Mr Gregory was described in the nursing notes as drinking, but his chart showed that he had drunk nothing since a cup of tea at 8.20am. The ambulance was called at 5.17pm. The fact that he had not drunk the whole day was not escalated to a senior member of staff and there was no evidence that any steps had been taken to deal with this. His fluid intake chart recorded him as repeatedly declining drinks, even at a time after he had lost consciousness and an ambulance had already been called for him. This demonstrates that the chart was inaccurate. It raises the possibility that the chart was inaccurate in other ways. It raises the possibility that when Mr Gregory was described as declining drinks, in fact staff were not taking any steps to encourage him to drink, or to eat. ”

Is this part of a recurring concern?

Yes — Unreliable recording of fluid balance information.

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

Roll out Restore2 deterioration monitoring, placing records in care plans and requiring monthly nursing updates.

Verbatim wording from the response

“To supplement this, since April 2020, Muriel Street has also rolled out the Restore2 deterioration tool (which is based upon the NEWS2 system commonly used across actual hospitals). A copy of the Restore2 documentation is attached and is contained within each resident's care plan file, and updated monthly by a nurse. The Restore tool assists staff members to be able to recognise the early signs that a resident may be deteriorating (as per the Significant 7 course), and then guides nursing staff on appropriate escalation and frequency of monitoring if required to ensure a resident is provided with timely and appropriate medical intervention. It should also be noted that the tool recognises that not all residents are the same, and therefore there is the ability to record additional signs of possible deterioration specific to a resident.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 4 · response
Published 9 April 2020

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

Disseminate wheelchair-safety guidance through laminated copies at nurses’ stations and copies in relevant resident care-plan folders.

Verbatim wording from the response

“Further, there is now a laminated copy of this guide at every nurse's station to ensure that the guide is easily accessible. Additionally, where a resident's care plan requires the use of a wheelchair, a hard copy of the guide is placed into that resident's care plan folder in their room.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 2 · response
Published 9 April 2020

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 full-group refresher training on wheelchair safety, appropriate dressing, oral-fluid encouragement and updated welfare-check documentation after restrictions are lifted.

Verbatim wording from the response

“As is clear from the above, there has been a number of changes made since the death. Ordinarily group training would be provided in order to re-inforce the improvements made. However, given the current pandemic, this has not been possible, and training has instead taken place in smaller groups. Notwithstanding this, once the current restrictions have been lifted, it is the intention of Muriel Street to have full group training on the following relevant areas:”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 6 · response
Published 9 April 2020

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

Increase staffing and senior oversight on each floor by adding senior managers and team-leader walkarounds.

Verbatim wording from the response

“Muriel Street has also increased staffing levels since this incident, and there is now an increased senior presence on each floor with a senior manager (Deputy Manager, Clinical Lead or Care lead) based in each nursing office and the addition of a team leader who supports to carry out regular walk arounds of their floor / unit. The result of this is greater oversight of staff activities and monitoring of residents to ensure that residents' needs and safety are maintained.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 2 · response
Published 9 April 2020

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 mandatory room-based training on encouraging oral-fluid intake and refresher techniques after pandemic restrictions are lifted.

Verbatim wording from the response

“Additionally, once the current restrictions in place due to the pandemic are lifted, Muriel Street will be undertaking mandatory training on room training for staff, part of which provides training to staff on the need to encourage residents to increase oral intake generally, as well as refreshing techniques / methods to encourage residents to do the same.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 5 · response
Published 9 April 2020

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 a personal-care refresher course addressing appropriate resident dressing after pandemic restrictions are lifted.

Verbatim wording from the response

“It is the firm intention of Muriel Street that all staff will undergo a personal care training refresher course once the current pandemic and consequent lifting on restrictions allow.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 3 · response
Published 9 April 2020

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 daytime documented welfare checks and audit completion through the Home Manager’s daily random documentation checks.

Verbatim wording from the response

“Muriel Street also undertakes specific welfare checks upon residents at regular intervals throughout the day. Previously, whilst such checks would have been undertaken during the day as part of other care provision (e.g. during meal provision, or regular repositioning), there would be no separate documentation during daytimes. Having reviewed matters, since April 2020, in accordance with Care UK policy Muriel Street has now ensured that the welfare check sheets are completed during the day alongside the other documentation to food and fluid charts, activities log books, turning charts and daily notes in addition to at night where they were previously completed.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 2 · response
Published 9 April 2020

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

Reinforce appropriate-dress requirements through senior meetings, handovers, wardrobe posters and care-plan documentation reminders.

Verbatim wording from the response

“Since this incident, the requirement to ensure that resident's are appropriately dressed was specifically discussed during the daily "Take 10" meetings for senior staff, and during handovers when all other staff would attend. During these meetings, posters, which are now placed in each resident's wardrobe, outlining examples ways in which a resident may wish to be dressed depending upon the weather, drawing upon the circumstances of Mr Gregory as an example of an unacceptable standard of care. Further, staff were reminded of the requirement to document any issues with clothing (e.g. non-compliance) within a resident's care plan file.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 3 · response
Published 9 April 2020

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 clearer fluid-balance and fluid-target charts, train staff in their use, and include them in documentation audits.

Verbatim wording from the response

“Muriel Street has reviewed the fluid charts used and has introduced new fluid balance monitoring documentation – copies attached. The new charts are clearer and enable details of a resident's input / output to be recorded in more detail. Further, staff are now instructed to document when the re-attempt to provide oral fluids to ensure that there is evidence of active encouragement.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 5 · response
Published 9 April 2020

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

Strengthen wheelchair-safety training with dedicated guidance and complete one-to-one supervision sessions for all staff.

Verbatim wording from the response

“Notwithstanding this, since Mr Gregory’s sad death, Muriel Street has reviewed the manual handling training provided. Following this, it was identified that the training surrounding the use of wheelchairs could be strengthened. Consequently, the training has been improved, and the manual handling training now includes a specific section on wheelchair safety guidance. This includes highlighting and working through the "How to Guide – Wheelchair safety Guidance" (copy attached) during the training session. Due to the current pandemic, and the consequent restrictions placed upon the ability to provide group training, Muriel Street has undertaken 1:1 supervision / training sessions with all staff members in order to go through the how to guide, and ensure staff are familiar with the expectations set out therein.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 2 · response
Published 9 April 2020

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

Educate staff about encouraging oral-fluid intake through meetings and provide hydration guidance in resident care-plan folders.

Verbatim wording from the response

“Since the death, Muriel Street has started and continues to educate staff of the need to encourage residents with oral intake of fluids. This has been done during "Take 10" and handover meetings. During these meetings all staff have been advised of the reasons why encouragement of oral fluids is so important, followed by an explanation and discussion of the ways of working and how to guides. Further, hard copies of these guides are now included in the resident’s care plan file in their room. This provides easier staff access to the guides and serves as a constant reminder to staff of the importance to encourage oral fluid intake.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 5 · response
Published 9 April 2020

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 incident occurred on arrival at Muriel Street, not during hospital readmission, and the resident was neither in public nor unresponsive.

Verbatim wording from the response

“For completeness, our understanding of the evidence, supported by the documentation from the family, is that the incident when Mr Gregory was found unsecured in a wheelchair was on arrival at Muriel Street, and not on the day he was readmitted to hospital. Further, our understanding of the evidence is that Mr Gregory was not in a public place, nor was he unresponsive at this time. That said, he should have been transferred into an armchair in his room.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 1 · response
Published 9 April 2020

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

Acute concerns about a resident’s oral fluid intake should be referred to the visiting GP for consideration and advice.

Verbatim wording from the response

“at weekly clinical review meetings). Further, in the event of more acute concerns in relation to oral fluid intake, the matter should be raised with the visiting GP to consider and advise, as occurred in Mr Gregory’s case.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 5 · response
Published 9 April 2020

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.4

  1. 1

    Participate in a local-authority trial of Whazam electronic vital-observation monitoring and escalation software.

    Stated by Care UK Community Partnerships LtdStated in progressThe respondent said that this action was in progress when they made their response on 9 April 2020.
  2. 2

    Train all staff in Significant 7, register the Home Manager as a trainer, and include the course in new-staff induction.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 9 April 2020.
  3. 3

    Provide clinical-skills workshops for nursing staff covering recognition and monitoring of deteriorating residents.

    Stated by Care UK Community Partnerships LtdStated completedThe respondent said that this action was complete when they made their response on 9 April 2020.
  4. 4

    Hold group staff meetings and lessons-learned sessions discussing the case concerns and resulting changes after restrictions are lifted.

    Stated by Care UK Community Partnerships LtdStated plannedThe respondent said that this action was planned when they made their response on 9 April 2020.

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

Participate in a local-authority trial of Whazam electronic vital-observation monitoring and escalation software.

Verbatim wording from the response

“The Restore 2 system is a paper based system. In order to seek improvement, the nursing unit at Muriel Street is part of a trial, involving a number of other organisations in the local authority area, of an electronic monitoring system called Whazam. This system allow staff to electronically record a resident's vital observations and then calculates a NEWS2 score, prompting actions as necessary. The electronic system also shares a resident's vital observations with local GP surgeries and if necessary the London Ambulance Service, to ensure speedy and effective transfer of vital information should the need arise.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 4 · response
Published 9 April 2020

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

Train all staff in Significant 7, register the Home Manager as a trainer, and include the course in new-staff induction.

Verbatim wording from the response

“Further, Muriel Street has also undertaken a significant amount of focussed learning and training of both clinical and care staff in relation to the identification and escalation of a potentially deteriorating resident. This has been done via the Significant 7 training package, which is a training tool developed and administered by NELFT NHS Foundation Trust. The course is designed to enable non-clinical staff to identify and act upon "soft" signs of deterioration. Broad details of the course can be found at https://www.nelft.nhs.uk/significant-7. Since September 2019, the Home Manager at Muriel Street has become a registered trainer for the Significant 7 course, and all staff at Muriel Street have undergone the Significant 7 course. It also now forms part of the induction training for new members of staff.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 4 · response
Published 9 April 2020

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 clinical-skills workshops for nursing staff covering recognition and monitoring of deteriorating residents.

Verbatim wording from the response

“Additionally, since Mr Gregory's death, all nursing staff have undertaken a clinical skills workshop, part of which deals with the identification of the deteriorating patient and monitoring of the same, details of which are attached. Part of this course deals with the Restore2 deterioration tool which has now been rolled out at Muriel Street – details of which are below.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 4 · response
Published 9 April 2020

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

Hold group staff meetings and lessons-learned sessions discussing the case concerns and resulting changes after restrictions are lifted.

Verbatim wording from the response

“Additionally, Muriel Street would usually hold regular staff meetings / lessons learned sessions. Again, due to the number of staff, this has not been possible due to the current restrictions. However, once such restrictions have been lifted, Muriel Street intend to have a series of group staff meetings and lessons learned session during which the issues and concerns raised as a result of this case, and the changes made will be discussed in full.”

Source location

2020-0073-Response-from-Care-UK_Redacted
Page 6 · response
Published 9 April 2020

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