PFD report

Francis Leech · Prevention of Future Deaths report

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Issued 2 Jun 2026•Worcestershire

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
4

Raised in this report

Recipients
2

Named on the report

Responses found
1

Of 2 recipients

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 raised4

  1. Lack of management system for checking and ensuring care and behavioural support plans are updated
    Part of recurring concern: Unreliable care-planning processes
  2. Lack of staff understanding of the importance of updating care and behavioural support plans
    Part of recurring concern: Inadequate staff competence in care planning
  3. Failure of internal investigations to identify care-plan deficiencies and prevent their repetition
    Part of recurring concern: Inadequate safety incident investigations
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

    Require dementia expertise to assist investigations involving residents living with dementia.

    Stated by Adept Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
  2. Action

    Issue management instruction reaffirming plan reviews, amendments and supporting risk assessments.

    Stated by Adept Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
  3. Action

    Conduct monthly audits of resident care and behavioural support plans.

    Stated by Adept Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.

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

  1. Position

    Current arrangements for oversight of care and behavioural support plans are considered appropriate in all the circumstances.

    Stated by Adept Care Homes LimitedExisting 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

Lack of management system for checking and ensuring care and behavioural support plans are updated

Wider context from the report

“The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated. ”

Is this part of a recurring concern?

Yes — Unreliable care-planning processes.

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 staff understanding of the importance of updating care and behavioural support plans

Wider context from the report

“The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated. ”

Is this part of a recurring concern?

Yes — Inadequate staff competence in care planning.

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 of internal investigations to identify care-plan deficiencies and prevent their repetition

Wider context from the report

“The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated. ”

Is this part of a recurring concern?

Yes — Inadequate safety incident investigations.

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 update care and behavioural support plans to reflect aggression, risk and risk-reduction measures

Wider context from the report

“The care home resident who inflicted the facial injuries on Mr. Leech lived with advanced dementia, and over the six weeks leading up to that incident had been showing signs of unpredictably aggressive and violent behaviour. Although many of these episodes had been the subject of incident reports, neither his care plan nor his behavioural support plan had been properly updated to reflect these episodes, the risk which he presented, and measures to be taken to reduce that risk. The evidence at inquest showed that: (a) staff at the care home did not understand the importance of updating the care plan and behavioural support plan; (b) management at the care home had not instituted a system of checking and ensuring those plans were updated; and (c) the internal investigation carried out by the care home after the assault on Mr. Leech failed to recognize the deficiencies in those plans, or to put in place measures to ensure that those deficiencies were not repeated. ”

Is this part of a recurring concern?

Yes — Failure to reliably develop and review risk-reduction plans; Unreliable care-planning processes.

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

Require dementia expertise to assist investigations involving residents living with dementia.

Verbatim wording from the response

“In respect of incident investigations, the Home acknowledges that the investigation into the incident involving Mr Leech did not identify gaps within the care plans and Behavioural Support Plans in place. Having reflected upon this, steps have been taken to require that an individual with dementia expertise assist in completing internal investigations where an individual involved is considered to be living with dementia. By introducing this additional expertise to the investigation process, we believe that this will allow for more in depth scrutiny of care arrangements and behaviours, and for appropriate actions to be taken.”

Source location

Response from Adept Care Homes (Bowood Court)
Page 2 · response
Published 21 August 2026

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

Issue management instruction reaffirming plan reviews, amendments and supporting risk assessments.

Verbatim wording from the response

“Following the conclusion of the Inquest into Mr Leech’s death, a further instruction was issued to the Home management and senior care team reaffirming the expectations in relation to the review and amendment of Behaviour Support Plans and the introduction of supporting risk assessments in reflection of lessons learnt. We would also note that a new Home Manager and Care Manager are now in place with oversight of the Home following the incident involving Mr Leech.”

Source location

Response from Adept Care Homes (Bowood Court)
Page 2 · response
Published 21 August 2026

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 monthly audits of resident care and behavioural support plans.

Verbatim wording from the response

“The Home’s management and senior care team are principally responsible for the creation, review and amendment of resident care plans and Behavioural Support Plans. Following creation, resident care plans and Behavioural Support Plans are reviewed and updated on a monthly basis or as required in response to changing resident care needs. Support from an individual with dementia expertise is also available to the Home to draw upon as required.”

Source location

Response from Adept Care Homes (Bowood Court)
Page 1 · response
Published 21 August 2026

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

Current arrangements for oversight of care and behavioural support plans are considered appropriate in all the circumstances.

Verbatim wording from the response

“Accordingly, the Home has taken steps to review the arrangements in place for the oversight of care plans and Behavioural Support plans which are now considered to be appropriate in all the circumstances.”

Source location

Response from Adept Care Homes (Bowood Court)
Page 2 · response
Published 21 August 2026

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

    Establish Home Manager and Care Manager oversight capacity.

    Stated by Adept Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
  2. 2

    Conduct twice-weekly spot checks of incident and accident report completion and provide feedback.

    Stated by Adept Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.
  3. 3

    Disseminate the Regulation 28 Report to the wider management team.

    Stated by Adept Care Homes LimitedStated completedThe respondent said that this action was complete when they made their response on 21 August 2026.

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

Establish Home Manager and Care Manager oversight capacity.

Verbatim wording from the response

“Following the conclusion of the Inquest into Mr Leech’s death, a further instruction was issued to the Home management and senior care team reaffirming the expectations in relation to the review and amendment of Behaviour Support Plans and the introduction of supporting risk assessments in reflection of lessons learnt. We would also note that a new Home Manager and Care Manager are now in place with oversight of the Home following the incident involving Mr Leech.”

Source location

Response from Adept Care Homes (Bowood Court)
Page 2 · response
Published 21 August 2026

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 twice-weekly spot checks of incident and accident report completion and provide feedback.

Verbatim wording from the response

“In addition, as advised during the Inquest, practices are now in place to ensure that spot checks are conducted on a twice weekly basis of incident and accident report completion and feedback is provided to the Home as required. This is in addition to their regular in person visits to the Home.”

Source location

Response from Adept Care Homes (Bowood Court)
Page 2 · response
Published 21 August 2026

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 the Regulation 28 Report to the wider management team.

Verbatim wording from the response

“I can confirm that a copy of the Regulation 28 Report has been disseminated to the wider management team for their consideration and that the below reflects the company’s response.”

Source location

Response from Adept Care Homes (Bowood Court)
Page 1 · response
Published 21 August 2026

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